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HomeMy WebLinkAbout0085 EMERALD LANE - Health 85 EMERALD LANE, IVIARSTONS MILLS LOCATION ^ `� Lc� e- SEWAGE-# VILLAGE 1Yuq1_S&S .w' J15' ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. -; SEPTIC TANK CAPACITY - 0 LEACHING FACILITY: (type) L ec,6'L / �, (size) NO.OF BEDROOMS 3— BUILDER OR OWNER PERMUDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet-of leaching facility) - - -Feet 1 Furnished by J� ar�ie� /�`�// '� � S/fP�f s K 6 �-C-3�- ° _h V 741 A G 81' 76, Ll O� o f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 Emerald Lane Property Address ��c•/ Joshua Curtice b Owner Owner's Name information is required for Marstons mills MA 02648 2-6-08 every 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. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Shawn Mcelroy cursor-do not Name of Inspector use the return key. Shawn Mcelroy Enterprises Company Name 29 Atwater Dr Company Address s ((— E. Falmouth MA 02536 I raun I City/Town State Zip Code 1-508-495-0905 S13971 ' Telephone Number License Number ' w Crj - �t B. Certification ' I certify that I have personally inspected the sewage disposal system at this address a d that tfie information reported below is true, accurate and complete as of the time of the inspecti n.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 2-6-08 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****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-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 15 f ` Commonwealth of Massachusetts W Title 5 Official Inspection Form = Subsurface Sewage.Disposal System Form -Not.for Voluntary Assessments r 85 Emerald Lane Property Address Joshua Curtice Owner Owner's Name information is Marston mills MA 02648 2-6-08 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order. No sign of backup. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass° section need to be replaced or repaired.The system,upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined(Y, N, ND) in the❑for the following statements. If"not determined,'please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection;if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage.backup or break out or high static water level•inthe distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed t5insp-08106 We 5 Mcial Inspection Form:Subsurface Sawaage Disposal System-Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 Emerald Lane Property Address Joshua Curtice Owner Owner's Name information is required for Marstons mills MA 02648 2-6-08 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.):. ❑ 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: 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. ; t5insp•08/06 Title 5 Official fnspecdon Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 Emerald Lane Property Address Joshua Curtice Owner Owner's Name information is required for Marston mills MA 02648 2-6-08 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 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. 3. Other: D) 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 ❑ ® 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 SAS,cesspool or privy is below high ground water elevation. El 01 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. t5insp•06/06 We 5 Official hispedion Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 Emerald Lane Property Address Joshua Curtice Owner Owner's Name information is required for Marstons mills MA 02648 2-6-08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nihate 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 2000gpd- 10,000gpd. ❑ ® 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 1S,000 gpd. For large systems, you must indicate either"yes or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well 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. t5insp•08106 Me 5 Officiall hispection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments & 85 Emerald Lane Property Address Joshua.Curtice Owner Owner's Name information is required for Marston mills MA 02648 . 2-6-08 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ®' ❑ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions,_depth of liquid,depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® 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-OaM TdL-5 Official 6upection Fwm:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a„ 85 Emerald Lane Property Address Joshua Curtice Owner Owner's Name information is required for Marstons mills MA 02648 2-&08 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available Past 2 years usage(gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: 2-6-08Date 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 Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Tale 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): t5insp-08/06 Title 50ffiaai lhspection Form.,Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y,N 85 Emerald Lane Property Address Joshua Curtice Owner Owner's Name information is required for Marstons mills MA 02648 2-6-08 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Owner-pumped two years ago Wass stem pumped as art of the inspection? Yes ® No y P P P P ❑ If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance Type of System: ® Septic tank,distribution box,soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (f yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contrail(to be obtained from system owner) ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed(if known)and source of information: 1980 Were sewage odors detected when arriving at the site? Yes No We g g ❑ ilffe 5 Official,to Form:,Subsurface Sawa a Disposal System•Page 8 of 15 t5insp•O8f06 spectton g po ys Commonwealth of Massachusetts Title 5 Official Inspection Form " Subsurface Sewage Disposal System Form -blot for Voluntary Assessments 85 Emerald Lane Property Address Joshua Curtice Owner Owner's Name information is required for Marston mills MA 02648 2-6-08 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 14"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. Septic Tank(locate on site plan): Depth below grade: 8"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 certficate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 1000 Gal Sludge depth: 10" Distance from top of sludge to bottom of outlet tee or baffle 22P Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape f5insp•OW06 Tie 5 Dffrct&frmpechm Form:Subsurface Se vW D'sposai System•Page 9 of 15 Commonwealth of Massachusetts " Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 Emerald Lane Property Address Joshua Curtice Owner Owner's Name information is required for Marstons mills MA 02648 2-6--08 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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 in good condition with all baffles in place. Recommended pumping for solids. 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.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal 0 fiberglass ❑polyethylene ❑ other(explain): t5insp"08106 Tide 5 Official':t spection.Form:_Subsurface Sewage Disposal System-Page 10 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 Emerald Lane Property Address Joshua Curtice Owner Owner's Name information is required for Marston mills MA 02648 2-&08 every page. City(rown State Zip Code Date of Inspection D. System Information (coot.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day 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 Distribution Box(if present must be opened)pocate 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. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5insp•08/06 TrdeSOffdal inspection Form.Subsncface Swage Disposal System-Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 Emerald Lane Property Address Joshua Curtice Owner Owner's Name information is required for Marston mills MA 02648 2-$08 every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number,length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number. ❑ innovat'nre/aitemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit in good condition. Old pit was 75%full and new pit was empty at inspection. historical stain line in new pit was 6"off bottom. t5insp•08/06 Title 5 Official:ftpectian,Form.Subsurface Smage Disposal System•Page 12 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection fora Subsurface Sewage Disposal System Form-Not.for Voluntary Assessments 85 Emerald Lane Property Address Joshua Curtice Owner Owner's Name information is Marston mills MA 02648 2-"8 required for - every page. CityfTown State Zip Code Date of Inspection D. System Information (cunt.) 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.): 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-08/08 Idle 5 of5aal'irapection,,Farm-Subswface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 Emerald Lane Property Address Joshua Curtice Owner Owner's Name information is required for Marstons mills MA 02648 2-6-08 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. A 6 Deck joD A -�- Q-D - ?C> A -F- 7/ ' L� 0 t5insp•08106 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts MMEM = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 Emerald Lane Property Address Joshua Curtice Owner Owner's Name t information is required for Marston mills MA 02648 2-6-08 every page. City/rown State Zip Code Date of Inspection D. System Information (cost.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to ground water: 20" 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 excavator's, installers-(attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS maps show groundwater at 20'. t5insp-0806 Trite 5 Official,'Inspection Force Subsurface Sewage Disposal System-Page 15 of 15 Town of Barnstable �p 1HE Tp� Regulatory Services BAMscnete Thomas F. Geiler, Director 9`�Arf 39 A& Public Health .Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition,by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the "Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. TOWN,,OF�pBARNSTABLE L&ATION �� -C �t C��"-- SEWAGE # a'II.LAGE ��`l 'l > ASSESSOR'S MAP &0 LOT -LIO INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FAClLrrY: (type) (size) NO. OF BEDROOMS BUELDER OR OWNER PERMUDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) �4 Feet Furnished by 9 IA 131 DetK a A017 bI Ac ys' A 3� 36 ac ss j-F COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Graci DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B..STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A 8 CERTIFICATION Property Address: 85 EMERALD LANE MARSTONS MILLS C)q�o G 31 U�6 Name of Owner THOMAS FOREST '! Address of Owner: SAME Date of Inspection: 4/13199 < , Name of Inspector:(Please Print)JOHN GRACI 11040c 999 I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000 ` Company Name: DEP TITLE V INSPECTIONS Mailing Address: BOX 2119 TEATICKET MA.02636 Telephone Number: 608-664-6813 k 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: X Passes The inpection Is based on criteria defined in Title V _ Conditionally Passes code 310 CMR 15.303.My findings are of how the system is Needs Further Evaluation By the Local Approving Authority performing at the time of the Inspection.My Inspection does Fails not imply any warranty or guarantee of the longgevity of the septic system and any of its components useful life. Inspector's Signature: Date:4/14/99 The System Inspector shall ubmit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection. f the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION.RECOM MEND PUMPING SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. revised 9/2/98 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 85 EMERALD LANE MARSTONS MILLS Owner: THOMAS FOREST Date of Inspection:4/13/99 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: nLa 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. nta The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. nta Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced n[a The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 85 EMERALD LANE MARSTONS MILLS Owner: THOMAS FOREST Date of Inspection:4/13199 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 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 ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone 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 nLa_(approximation not valid). 3) OTHER Wa revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 85 EMERALD LANE MARSTONS MILLS Owner: THOMAS FOREST Date of Inspection:4/13/99 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described 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 X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped nta. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X 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 ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: 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: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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 upgrade the system in accordance with 310 CMR 15,30412).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 85 EMERALD LANE MARSTONS MILLS Owner: THOMAS FOREST Date of Inspection:4/13/99 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X 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. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X 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: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) 11 5.302(3)(b)) X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5 of 11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 85 EMERALD LANE MARSTONS MILLS Owner: THOMAS FOREST Date of Inspection:4/13/99 FLOW CONDITIONS RESIDENTIAL: Design flow:-=g.p.d./bedroom Number of bedrooms(design): 3 Number of bedrooms(actual):.1 Total DESIGN flow: 23Q Number of current residents:2 Garbage grinder(yes or no):NQ Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no):M Seasonal use(yes or no):M Water meter readings,if available(last two year's usage(gpd): nLa Sump Pump(yes or no): NO Last date of occupancy: nLa COMMERCIAL/INDUSTRIAL Type of establishment: Wa Design flow: Wa gpd(Based on 15.203) Basis of design flow: Wa Grease trap present:(yes or no): �LQ Industrial Waste Holding Tank present:(yes or no): NQ Non-sanitary waste discharged to the Title 5 system:(yes or no):NO Water meter readings.if available:Wa Last date of occupancy: nLa OTHER: (Describe) nla Last date of occupancy: nLa GENERAL INFORMATION PUMPING RECORDS and source of information: NOT IN THREE YEARS System pumped as part of inspection:(yes or no): If yes,volume pumped 111t10 gallons Reason for pumping: MAINTENANCE TYPE OF SYSTEM X Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes.attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: nLa APPROXIMATE AGE of all components,date installed(if known)and source of information: ORIGINAL SYSTEM IN 77 WITH A NEW PIT IN 95 Sewage odors detected when arriving at the site:(yes or no): NQ revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 85 EMERALD LANE MARSTONS MILLS Owner: THOMAS FOREST Date oflnspection:4/13/99 BUILDING SEWER: (Locate on site plan) Depth below grade: IC Material of construction:_ cast iron _40 PVC X other(explain) Distance from private water supply well or suction line: TOWN Diameter: nLa Comments: (condition of joints,venting,evidence of leakage,etc.) D& SEPTIC TANK: X (locate on site plan) Depth below grade: IE Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) nLa If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NQ D& Dimensions: L 8'6"'H 5'7"W 4'10" Sludge depth: U Distance from top of sludge to bottom of outlet tee or baffle: 2E Scum thickness: 7" Distance from top of scum to top of outlet tee or baffle:6 Distance from bottom of scum to bottom of outlet tee or baffle: iL" How dimensions were determined: MEASURED 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.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING SYSTEM EVERY TWO YEARS GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) nla Dimensions: n& Scum thickness: nLa Distance from top of scum to top of outlet tee or baffle:li& Distance from bottom of scum to bottom of outlet tee or baffle nLa Date of last pumping: n& 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.) nLa revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 85 EMERALD LANE MARSTONS MILLS Owner: THOMAS FOREST Date of Inspection:4/13/99 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: n/a Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) nLa Dimensions: Wa Capacity: Wa gallons Design flow: Wa gallons/day Alarm present: NQ Alarm level:j3t& Alarm in working order:Yes—No—: NO Date of previous pumping: n& Comments: (condition of inlet tee,condition of alarm and float switches,etc.) nLa DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert:LIQUID LEVEL WITH BOTTOM OF PIPE Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) DISTRIBUTION BOX IS STRUCTURALLY SOUND PUMP CHAMBER: NO (locate on site plan) Pumps in working order:(Yes or No): WQ Alarms in working order(Yes or No): 11LO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) nLa revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) .Property Address: 85 EMERALD LANE MARSTONS MILLS Owner: THOMAS FOREST Date of Inspection:4/13/99 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: nta Type: leaching pits,number: 2-1000 GALLON LEACH PITS leaching chambers,number: ._n1a leaching galleries,number: _nLa leaching trenches,number,length: n& leaching fields,number,dimensions: n& overflow cesspool,number: n& Alternative system: n(a Name of Technology: _n/A Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PITS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY THE OLD PIT WAS FULL,THE NEW PIT AHD 2.5'IN IT. CESSPOOLS: _ (locate on site plan) Number and configuration: n& Depth-top of liquid to inlet invert: n& Depth of solids layer: n& Depth of scum layer. DLa Dimensions of cesspool: nta Materials of construction: n& Indication of groundwater: nta inflow(cesspool must be pumped as part of inspection)n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Dla PRIVY: _ (locate on site plan) Materials of construction:nfa Dimensions:n& Depth of solids: Wa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nLa revised 9/2198 Page 9 of 11 i r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION E TION FORM PART C SYSTEM INFORMATION(continued) Property Address: 85 EMERALD LANE MARSTONS MILLS Owner: THOMAS FOREST Date of Inspection:4/13/99 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a Dec(� D (� d lbp�- I OD AC 41L lAD 7( AC W1 � 3a 3° revised 9/2/98 Page 10 of 11 I V r Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 85 EMERALD LANE MARSTONS MILLS Owner: THOMAS FOREST Date of Inspection:4/13/99 NRCS Report name: n(a Soil Type: Wa Typical depth to groundwater: Wa USGS Date website visited: nla Observation Wells checked: NO Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar _ Shallow wells Estimated Depth to Groundwater 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record X Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions _ Checked with local Board of health Checked FEMA Maps _ Checked pumping records _ Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS AND VISUAL-12+FEET revised 9/2/98 Page 11 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM a ' Address of property B / �'•�r:��-,r �1,^F Nu rsi;s /V 1�s ��•, ' Owner's name a:,�,', .�1.�;, Cb Date of Inspection J,,l�, S'J �q s E�VEO PART A U L 1 9 1995 CHECKLIST ��aw Check if the following have been done: w Pumping information was requested of the owner, occupant, 0 H of Health. wy -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. C5 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. w, The site was inspected for signs of breakout. ( , -7V15 A1.1 system components, excluding the SAS, have been located on the site. a�_ 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. Q3 The size and location of the SAS 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 SSDS. . a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM KART B SYSTEM INFORMATION I P11 FLOW CONDITIONS If residential i 3 number of bedrooms . I number of'•current residents A/c— garbage grinder, yes or no- laundry'. connected to system, yes or no seasonal' use, yes or no If nonresidential, calculated flow: Water meter readings, if available: it/rl� i Last date of occupancy I E GENERAL INFORMATION Pumping records and source• of information: f Aii h/1 /i.!•• !LC•I IJT O'� .[cfr lM:tvJ rs'i Li '• k9 Q(4'P�-�l'' �a Imo" J System pumped as part of inspection, yes or no if yes, volume pumped Reason for pumping: i Type of system i _ Septic tank/distribution box/soil absorption system 3 Single cesspool Overflow cesspool i 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. Source of information: 4 u Sewage odors detected when arriving at the site, yes or no r . r t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B r SYSTEM INFORMATION continued t SEPTIC TANK: '1 (locate on site plan) depth below grade: ,c material of construction: ✓concrete metal FRP other(explain) dimensions: S''aA XY� /000:5� S� 3 sludge depth —1y' distance from top of sludge to bottom of outlet tee' or baffle a" scum thickness OY— 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 sof leakage, recommendations for repairs, etc. ) �o��%ti0n - �i oo�/ it/n Gov J�• cc y� /ea lfot5,-, 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, recommendation tfor repairs, etc.) c.�,g/, /� On DT 6ox .A S 1210100�. H& f 0-r' le-o Lo,✓-r :?,A" �yyrAof��Sr tPT Te a�'yer7� v+�a re �".6w 7►� nt�✓ L�4c� e;� PUMP BER: cate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, ` recommendations for maintenance or repairs,etc. ) I • 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued 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, ex lain: 2,9 't Ay Type -"leaching pits and number � ` ,fS leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number Comments: (note condition of soil , signs of hydraulic failure, level of pondirig, . condition of vegetation, recommendations for maintenance or repairs,etc. ) w level, ,' . Qa�P4rs 7 br -r .Cfi'v.�,•,s 1' .b ro�Pr/cam ,� OLS (locate on site plan) : 1 number a onfiguration depth-top of id to inlet invert depth of solids lay depth of scum layer dimensions of cesspool materials of construction indication of groundwater inflow (cesspool m e pumped as part of ins on) Co nts: . (note condition of soil, signs of hydraulic failure, level 'of pondin condition of vegetation reco e recommendations .for maintenance or repairs,etc. ) (locate site plan) materials of cons ion dimensions depth of solids Comments: (note condition of , signs of hydraulic failure, - of p ondin 'condition o getation, recommendations for maintenance or re _etc.) —� 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION PORK PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' r,4�' 9 3 s6 ' yb A z '72 .,. ' S `7 o $,2 ap ►-=-1 DEPTH TO GROUNDWATER �s depth to groundwater method of determination or approximation: A, &-4eel of 615 ►-►�4a R-.� 6ia,�.lwti�Xt�' T�w*n a 40 Goa/H5-tr h/�./A G��sy 12 <: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORK PART C � . FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined", explain why not) /✓ Backup of sewage into facility? A Discharge or ponding of effluent to the surface of the ground or surface waters? /' Static liquid level in the distribution box above outlet invert? /1e"' Liquid depth in cesspool <6" below invert or available volume< 1/2 day flow? /✓ Required pumping 4 times or more in the last year? number of times pumped _�✓ Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? , Is any portion of the SAS, cesspool or privy: below the high groundwater elevation? _Al within 50 feet of a surface water? A within . 100 feet of a surface water supply or tributary to a surface " water supply? within a Zone I of a public well? X1 within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? within 50 feet of a private water supply well? /V 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. . 13 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector jo��,'� Company Name Company Address �.Sv 4�lal •,t ST /LI, Certification Statement _ I certify that I have personally inspected the sewage disposal system at .this address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and manitenance of on-site sewage disposal systems. Check one: _V' I have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15. 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15. 303 . The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector's Signature �. Date Ju s/ Original to system owner Copies to: Dznrr Buyer (if applicable) Approving authority TOWN OF BARNSTABLE LOCATION SEWAGE # 9S- /;i F VILLAGE**tyg,vg ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY CX1ST/1J6- 7-A;,U . LEACHING FACILITY:(type) Lr4ci4 Pir LN�w� (size) !;O© NO. OF BEDROOMS EWSWiN6- RITE WEL OR PUBLIC WATER BkaL-XWR OR OWNER DATE PERMIT ISSUED: /�Oi�„Q,, � 1996— DATE COMPLIANCE ISSUED:- VARIANCE GRANTED: Yes No r ,t } Ni� 60f�GA-i Cep E�t�srin��- [.Pe y o Ewsr i i 7-G A 3 7z 7 No....?5-/3v Fr�$....�� ..- .... THE COMMONWEALTH OF MASSACHUSETTS rr� BOAR® OF HEALTH v `t� � 039 TOWN OF BARNSTABL.E Appliratiun for Di-nipagal Murk.6 Tunutrnrtiun Permit Application is hereby made for a Permit to Construct ( ) or Repair (A-")'—an Individual Sewage Disposal System at: , Fr . .... �hH -:� �r G•srs 'lih, 5'S / .,or LVfLocA .................. .......................................i ------•.... --...� . --••-•/ i l ..................................... j O erg Addr ss a �t� Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling— No. of Bedrooms----.�J____________________ __ .Expansion Attic ( ) Garbage Grinder (X� Other—Type T e of Building ............................ No. of ersons-_.__--___-__-_-_____---_.-- Showers — a yp g p ( ) Cafeteria ( ) Q' Other fixtures ---------------------------------- W Design Flow--------------------------------------------gallons per person per day. Total daily flow..------------------------------------------gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width__.__.------_- Diameter_.------------ Depth................ x Disposal Trench—No. .................... Width.................... Total Length-------------------- Total leaching area....................sq. ft. 3 Seepage Pit No...................... Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ a -------------- --•-- r 0 Description of Soil--------------------------�!tn.4 ----------------•------------------------- ................................................................................ x W ................................................ .............................................----------------- UNature of Repairs or Alterations—Answer when applicable.._.__ ...__ 4--�..v .....�.'w ��a--{�N�../ •-------•-------------------------------------------------------•-••-••----•-------------------------••----•-...._..-----•--....-----••-•-••-••----•---------•------•------•-----------•---------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliant s en issued by the board of health. Signed ............ .......... ......(/........... :1., i5 9S ---- ------------------------------------ ---------------------------------------- Dace Application.Approved By ... DoA------- - --i.------------------------------ Application Disapproved ._..............-----------------_...----...........------------- Dace Application Disapproved for the following reasons- ------------------------------------------------------- ---------------------------------------------------------- -------- ------------------------------------------------- --------- -------- ---- --- ---------------------- // O - 9 - ! J Dace PermitNo. 2......................... .................... Issued -----------------------------------------------------.----------- Dme Nn THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH � �'�� �7 � TOWN OF BARNSTABLE Apli iratiuit for Bispusttl Vork.5 Tomitrur#inn ramit Application is hereby made for a Permit to Construct ( ) or Repair (�an Individual Sewage Disposal System at: gs- ��pv�.�� �ur�. /*ys/":-,.6�;//s ......................•------..........----•----------.......------.....----•------........------• ----------••••----------•-••---------------------------•.......-•---------.....-------•••--------- :Location-:\d ry�ss _..{ / .� ��HN/$ /�. /l/lprLo� <>/5/lsiyS _���/f ......................_..... ............................................... ........................................................... y v/ O�tiper/ / Addr ss � �7 /7• %, l l� --- sv_ A/•too,J�._sY,_ - ��GJ-S/vyl s a .......................•-- ....-•---------- --•---•. Installer Address PQ UType of Building Size Lot............................Sq. feet Dwelling— No. of Bedrooms-----2----------------------------------Expansion Attic ( ) Garbage Grinder (XI aOther—Type of Building ._------------------------ No. of persons----------....-_-.--_-----.- Showers ( ) — Cafeteria ( ) d Other fixtures ------------------•-------------------------------•--- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity--_-.-.--...gallons Length---------------- Width---------------- Diameter_-_-..---.------ Depth................ x Disposal Trench—No. .................... Width-------------------- Total Length.--..-----_----_-- Total leaching area....................sq. ft. Seepage Pit No..................... Diameter----.---------.----- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) a `Percolation Test Results Performed by........ ----------------•---••--•.....--------•---•-----------•-•••--•-•- Date........................................ Test Pit No. I................minutesaper inch Depth of Test Pit-------------------- Depth to ground water...---.----------------. (s. Test-Pit No. 2................minutes,,per inch Depth of Test Pit.................... Depth to ground water........................ 04 ---------- ----- ------ O Description of Soil.................................' - - - ..... x W ....................... ---------------------------------------------------------------------------- ---------" ' U Nature of Repairs or Alterations—Answer when applicable....-., --S�I�--0,4' l &V �tsar / ��-------------------•... -----------------------••-•--------........ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until-a-Certificate of Compliant 'hi s h6en issued by the oard of health. • - - - -- Signed ...... --------------- ------------------------------- ------------........------------------- Date Application.Approved By -----,C_�- �Y-----"� �!r '�,. .r� ----�---.1G_-................. Date Application Disapproved for the following reasons- ------ ----------- --------------------------------------------------------------------------------------------------------- ---------------------------- ------------------------------------------------------------------------------------------------------------------------ ----------------------------------------------- . .... ._.................. l'7,L-- l l O Date PermitNo. - --- - - ---------------------- -------------- Issued ......................... .......... . . ...... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C�er#muttk of C11ompliance THIS IS TO CERTIFY, Th t the Individual Sewage Disposal System constructed ( ) or Repaired ( �)' by �� FI 1G ;t- .............._....... -..... ....---------------------- -------............-----------.----------_----- ----------------- .------------------------.------------ ------------------------------------------ at ...........5----. rve.� .....4ef".f ......._ �G/-S h ... y// 15 has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. -------- ----------- dated *,/`t:5...................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUAR2.�b►NTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. ----------------- Ins ect�r ... _- �- DATE...._ Jf'.��r--•� p . r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No......................... FEE........................ Dispnsal Workii Tnnstrudinn "rrntit Permission is hereby granted...........J"4'-.............................................4 A, ------------------•------------•------...-----•......--•---................. to Construct ( ) or Repair ( (-)`an Individual Sew ge Disposat System at No........... .. �•....orulc ---��=............---� �<ie5.o�. .... ../5---------------------•--------- / Street 4� /3 U .� i as shown on the application for Disposal Works Construction�Permit No.- -----._ Dated-----f--��-�--=--------......._._.... --•.. .................-•-- A'' ----------------------•------------------ Board of Health DATE....... / -----r' FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS lO`CAT ION '"``�`' ' `� SEWAGE PERMIT NO. i2MA.L1, T,4r12�s VILLAGE IN.STA LLER'S NAME & ADDRESS B U I'l D E R OR OWNER DATE PERMIT ISSUED 1 OAT E : CO-MPLIANCE ISSUED � � 7 7 7 fJ� i 7;_ �7 No.--------- g'�� - Fps..../--:7 ........... THE COMMONWEALTH OF MASSACHUSETTS BOARD F HE LTH fl.----------.OF...... Apphratiun -for 43hip al Workii Towiftnrtiun Vamit Application is hereby'made for a Permit to Construct ( a-5 or Repair ( ) an Individual Sewage/ispnosal System at: N1.:._ M....................................U..�l-------------------------------------------- i/ Location-Address or Lot No. sLcd r .....--- /................... ! N M,........................................ Owner t Address a �i G -----------------------------------•----------••---------------•- ------- --------- f/6"O" ............................................................................ Installer - Address UType of Building S�r�T bs)s Size Lot.1c,-__ _ 6'_ -----Sq. feet Dwelling—No. of Bedrooms......3-----------------------------------Expansion Attic ( ) Garbage Grinder (Ala) aOther—Type of Building ............................ No. of persons_-______-_---____-_--_---__ Showers ( ) — Cafeteria ( ) G4 Other fixtures ---------- ---- ---------•---•- - W Design Flow_______________5".0............_.........gallons per person per day. Total daily flow..............iF_L-__'_-__-____--..-_.-_..gallons. WSeptic Tank+Liquid capacitvj_r.t.r.gallons Length....%_........ Width...... Diameter----- Depth.-T..°..._._. x Disposal Trench—No--------------------- Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No------- Diameter----- Depth below ' let_ r'49C_�:"*....._sc ft. p ____ _._.__ Total leaching area._ _. 1. z Other Distribution box ( ) Dosing tank ( ) ® /"G � c.T—l7 - 77 Percolation Test Results Performed by---------- ------------ ------------------------------ Date---------------------------------------- a Test Pit No. 1................minutes per inch Depth of "Pest Pit.-.-_-_______-___ - Depth to ground water..-----.._.--..-- fi Test Pit No. 2----------------minutes per inch Depth of Test Pit.-__-__---...__-____ Depth to ground water------------------------ ------------------ . -•---•••• ... ---•--... --•------ --.------ O ri t Description of Soil -- -------- -. " .. x U - ------J---- ...... Ge a _,.9E.......� W ------------------------------ ------------------------------------------------•----------------------------------------------------------- ------------------------------------------------------ V Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. SIgd..... i ''` ----------------------------------------------------------- ` Date Application Approved By---------- 4 ----- � ..-. /—..at Date Application Disapproved for the following reasons:----------------------------------------------------------------------------------------------------------------- -------------------•--...---------•----------•------••--••-•-----------•------•--•-----------•---•-------••---••--•------------•----•--------•---------------....-•-•-------------•--•••-•-------------- Date PermitNo......................................................... Issued....................................................... Date - o . THE COMMONWEALTH OF MASSACHUSETTS 'f BOARD F HE LTH Appliratinn -for Ditipa-4al Morkii Cnonstrurtton Puniit Application.is hereby'made-for a Permit to Construct (kj- or Repair ( ) an Individual Sewage Disposal System at: LQ ...... ..-'°-y-----�r...............................r _...--...lvL:._ I!2 0 < 5 0 y _ Location-Address or Lot No. u l-L/ n` + =I' 1`!:`••g', Go ................... ..... hfit•,5. Owner [ Address at':...__.._.._!...-.?......-•--- -------•-••--------•--•--•-- -------------------- Installer Address U Type of Building SA tT /JO A Size Lot.1c,___U?'.!-----Sq. feet Dwelling—No. of Bedrooms------3-----------------------------------Expansion' Attic ( ) Garbage Grinder (A/p) aq Other—Type of Building ___________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures W Design Flow...............4".Q_______.__..__..__.__..gallons per person per day. Total daily flow-------------3_4_A.......................gallons. 1:4 Septic Tank+-Liquid capacity j.4_o D__gallons Length----9......... Width------A-.'---.. Diameter_________ _____ Depth-J------------- Disposal Trench—No-____________________ Width-------------------- Total Length_-_____._-____...... Total leaching area--------------------sq. ft. Seepage Pit No......1------------- Diameter_____G_.__`._..._-_. Depth below • let__ .._61___. ___.__ Total leaching area..&IZj� ...___.sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Qp - G -• t�'"'/7- 77 Percolation Test Results Performed by----------------------- ------------------------------------------•------- Date_-___--------------------------•------- a Test Pit No. L_______________nrinutes per inch Depth of "Pest Pit.................... Depth to ground water.-______---_----.--.. f14 Test Pit No. 2----------------minutes per inch Depth of Test Pit__::;______________ Depth„to ground water__-_--_-___-________._. tx -••- - ;,_ ._._. = D Description oftSoil -+ / v /V �- x �_._....... ----- ---- �9�... W U Nature of Repairs or Alterations—Answer when applicable._-__..________________------------------------------------------------------------------------ ------------------------------------------- .. ------•----- ----•------------------ -------------------------- Agreement: ,t; ,. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article NI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health.: tSig fd----- - --- l--------`-------------------------------- 3 ! _ ___ Date Application Approved BY e �.1 � .- -------------------- �'" '�t!I` �� -------- Date Application Disapproved for the following reasons:.........-------------------------------------------------................ ----__. ------------- -----------•-••- Date Permit No.......................................................... Issued............ -__:- - Date r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH w1rdif iratr of Tomplitturr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (Y) or Repaired ( ) okAt " Installer at--- -t'sc y Goa-_..__1 A.,uZ.-•--------••-- has been installed in "tordance with the provisions of Art• e _- The State Sanitary Code as described in the application for Disposal Works Con struct{oit-Permit* No... ___._.__ _.__ -. ------- dated----_ :'-=/---'-`--7-7_________________ THE ISSUANCE OF THIS CERTIFICATE SHALL,NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE , ' C- �--------- _ /..------. Inspector_,.,::_.---o:l-.-- �► `°-`-------- ----------•------••-•-- THE COMMONWEALTH OF MASSACHUSETTS' �r BOARD O HEALTH ........ �r''LA..1!. _.....OF........... '...G..�s!ke dry.. No.........1.14..... FEE_... Permission is her grante �} to Construct (t/) or.Repair ( ) an Individual Sewage Disposal System at No.._!kq-u-_41......�`-- - :,_ Q... �' �'-•------...--••- t khe 4 -------------------------------------------------- - Street i as shown on the application for Disposal Works Construction P No. - E_ Dated____-97 4........................l '-'C -- ---- . .�" rj Board of Health DATE....... ..'�'_,/7---------------------------------------------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS a/ i t {:-,� '' i f rt r. r ktY ,,; Y l >• r + ' �'r. ���� sf+ ltl •. r �t, r r:. 4 `A'i � }j' ,..'�M1..i t, Y ,19;� � •',... '.A, ,, �.',' r ��Y,� ..i� t `� rt u'3 ' t� � 6Y A�t�!}�L•ii ��•,l 4! . r t ,.4! a ,. ' - •A i � r ,111���'r � t+y: c_ h Y:,� ,. g •�. ' s 'S ��'-t it �t.j'r��f".�rj'�rq�, ` Sy �• s !� .4-. >il k} :u A r rtt a :r :}• + /�iG r[/s,�7L «1. r�rr 4 #' Y r I'Y rc{, t 4.F) �' .�... i ' .. , _ r r - i i Y j:eh a yi'vt'f ' �` t•t f '�� x, C/S�hr/D x t r /_73. 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CERTIFY, THAT THE PLAN OF LAN D, a STRUCTURE STRUCTURE SHOWN HEREON WAS LOCATED r r BY AN "ACTUAL. FIELD SURVEY ON ON - 197 /. , AND ..CONFORMS TO THE' Y j ZO LNG BY LAW .OF THE TOWN OF L , MASSACHUS �S./ ,Y IN Y �rtix�4 a pr�ia -14 t` 'REGISTERED LAND 'SURVEYOR .`'.�x'�✓ 'S `"m%�. °�G 's MASS "Zc P �� ; `.' SCALE I°- r�'C�'r a; / 'r''°'t'L G �1977« �y�r f yror i V Aqafy ,,.. G°r DATE / i i � Fg}"fly �Y r�ylY 4�G DAMES } r � � CAPE COD SURVEY CONSULTANTS`t W►SWELL' A' DIVISION ' OF SOSTON SURVEY CONSULTANTSa�INC #, ' ' •}` a No. tlo2y p 132� aK w ROUT,ENp a 1 .y - r-'�a �, _ .e'1' {'•2lli j '- - - :. i rat»fit i 1 ) f�'cl 11, HYAfdNIS; MASS ,s r t :.' 1 �. '�}ry'. � •'r�r � ,,i .' �,y.`ti S x '9•�•�, ?y 1��,/ 4?`;r3Y� �r r r5 r Y y>r' '{ .,.t t y +� " > ' 9 i � • � 1,.4 Y � •tyr,,,�•y t�,Sy � s�?�, �''' � �' ,�4 S r`''.1•l kt 1 i..... ° t .l .. 4 .� � ° Y t i t ir�t,'Y.i. 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