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HomeMy WebLinkAbout0141 LAURIES LANE - Health 141 LAURIES LANE,MARSTONS MILLS A oil i I -_ TOWN o 1gARAi§TABLE c; 1& SEWAGE# rS s A�SSSSOR'S`A+#AP. LC}T 5 DWALLWS NAi LE&PHONE N4 SBPTIC TANK CAPACF!'X ���� LEACMG FACIL' Y•{type) �� Es ze) ��Q( NO OFBEDOGMS �t7IIDt OR©Wi�TER PEITDATE COAr€Pi;IAIYCE DAM Separation Dcstancc Betw�n Fhc MaxieiumAdjustecl GronndwaterT�bleto the Bottom of LeactengFaCilityt PnYat ' tatar 3upply'9Peli andl iing Faciiity m—' onus exist asrsits er cnttun?0�felt of le�chizg far. ity) T�eei' Edge of�lettand and I;each�ng f�aa` ty, aria wctlatids exist witxiiat 3DO feet o Ieaclutig fty r Feet. Furiiashed.b 6 a , 3 I -i��- - Commonwealth of Massachusetts oat TOD : f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Jam. ;,•�.;k� 141 Lauries Ln Property Address 'a Heidi Watanabe Owner Owner's Name information is required for every Marstons Mills MA 02648 9-26-17 E page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information ��# alo 3 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Service Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S 13971 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 16.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation Local Approving Authority 9-26-17 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 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. t,ins.cioc•rev.8/1, Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments t a�i l;!yi 141 Lauries Ln Property Address Heidi Watanabe Owner Owner's Name information is required for every Marstons Mills MA 02648 9-26-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A B C D or E always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. 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. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts :a=1 Title 5 Official Inspection Form � I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments is ar' ;�!✓ 141 Lauries Ln Property Address Heidi Watanabe Owner Owner's Name information is required for every Marstons Mills MA 02648 9-26-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 16.303(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 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts =^ t� Title 5 Official Inspection Form ,-I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments gF+ 9_ !+ 141 Lauries Ln Property Address Heidi Watanabe Owner Owner's Name information is required for every Marstons Mills MA 02648 9-26-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 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 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts :a=1 Title 5 Official Inspection Form .J� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 141 Lauries Ln Property Address Heidi Watanabe Owner Owner's Name information is required for every Marstons Mills MA 02648 9-26-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 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 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section 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 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. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form icy. �4 ; I Subsurface Sewage Disposal System Form Not for Voluntary Assessments ,'r `� y.1$!✓� 141 Lauries Ln Property Address Heidi Watanabe Owner Owner's Name information is required for every Marstons Mills MA 02648 9-26-17 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)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts :a=1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments or, 141 Lauries Ln Property Address Heidi Watanabe Owner Owner's Name information is required for every Marstons Mills MA 02648 9-26-17 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 9-2017 Date 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 Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form "l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments s#!, 141 Lauries Ln Property Address Heidi Watanabe Owner Owner's Name information is required for every Marstons Mills MA 02648 9-26-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts :a=1 Title 5 Official Inspection Form JSubsurface Sewage Disposal System Form -Not for Voluntary Assessments 141 Lauries Ln Property Address Heidi Watanabe Owner Owner's Name information is required for every Marstons Mills MA 02648 9-26-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1980's Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 24"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: 18"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: 12" t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 , Commonwealth of Massachusetts �al Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a� 141 Lauries Ln Property Address Heidi Watanabe Owner Owner's Name information is required for every Marstons Mills MA 02648 9-26-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 20" 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 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. 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 t5ins,doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts :a=1 Title 5 Official Inspection Form �'f�;I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 141 Lauries Ln Property Address Heidi Watanabe Owner Owner's Name information is required for every Marstons Mills MA 02648 9-26-17 page. City/Town 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.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day 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 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Lh Title 5 official Inspection Form Gtl _N Subsurface Sewage Disposal System Form -Not for Voluntary Assessments N s§ ' 141 Lauries Ln Property Address Heidi Watanabe Owner Owner's Name information is required for every Marstons Mills MA 02648 9-26-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from pit. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 i Commonwealth of Massachusetts f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 141 Lauries Ln Property Address Heidi Watanabe Owner Owner's Name information is required for every Marstons Mills MA 02648 9-26-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1-1000 gal ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit in good working order and holding 6"of water with stain line at 24" below inlet invert. 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 t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts al Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form Not for Voluntary Assessments 141 Lauries Ln Property Address Heidi Watanabe Owner Owner's Name information is required for every Marstons Mills MA 02648 9-26-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 f Commonwealth of Massachusetts a Title 5 Official Inspection Form -1�4 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 141 Lauries Ln t JS• Property Address Heidi Watanabe Owner Owner's Name information is required for every Marstons Mills MA 02648 9-26-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately f o I s � 3 ((jj' F+1 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 , Commonwealth of Massachusetts f Title 5 Official Inspection Form ; I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y_`_ss ✓ 141 Lauries Ln j Property Address Heidi Watanabe Owner Owner's Name information is required for every Marstons Mills MA 02648 9-26-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high 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 excavators, installers- (attach documentation) ® Accessed USGS database - explain: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at greater than 20'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts a= Title 5 Official Inspection Form 1 J ' l;4 Subsurface Sewage Disposal System Form Not for Voluntary Assessments 141 Lauries Ln Property Address Heidi Watanabe Owner Owner's Name information is required for every Marstons Mills MA 02648 9-26-17 page: City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 I .. -:6pXj.cl 4Tj Urn o ,r,{ B06 F`IEW,"SANITARY SERVICE 451'ROUTE 6A P.O. BOX 438 EAST SANDWICH. MASSACHUSETTS 02537 '�„(617) 888-2010 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION PORN Address of property /Y/ 4AUR11CS A/v. /►aAKs�'oN �P�6fs� MA • O 2 6Y� Owner's name 8A<6*4A 24 V0,/V Date of Inspection d♦ - PART A CHECKLIST : .. Check if the following have been Idone: Pumping information was" requested of the owner, occupant, and Hoard o Health. _v None of the system components$'have been pumped for at least two peeks 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. V As built plans have been,. obtained and examined. Note if they are not ;. available with N/A. V The facility or dwelling was inspected for signs of sewage Puck-up. The site wasinspected°"for'"signs` of breakout. All system components, excluding the SAS, 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 SAS on the site has been determined basee 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. . u,y 00 t l SUBSURFACE SEWAGE DISPOSAL SYSTEM INS r INSPECTION FGRM ' PART B SYSTEM,,!IINFORMATION FLOW CONDITIONS If residential 2 number of bedrooms �.,_! number-,, „o.f.g currents{resfdents. _ ^/ garbage grinder,' yes or ,.. no ¢ � t laundry connected_4toR'system, :yes,For no seasonal use, yes• ort•no' ' . ,If nonresidential, calculated flow: Water meter readings, if available: w,gTe Last date of:v'occupancy _GENERAL.INFORMATION Pumping,. records ,and; sourceyrof information:r.` _A* System pumped as part ' of inspection, yes or no if yes, volume pumped .�`;. Reason for pumping• 9'ype .of system ; ,.:Z Septic •tank/di•stribution }box�soil absorption system Single cesspool Overflow cesspool • ' Privy 1;. ''� � .t i a>K; R i � �• t k <;! s'= f�.,ri•, (.i i:$" .k- ,;,rc. � � ... 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 Information.- Sewage odors detected when arriving at the site, yes or no f • 8U88URFACE.'BEWAQE�IDISP08AL SYSTEM INSPECTION FORH PART B -SYSTEXIINFORMATION oontinued SEPTIC TANK:„JL. (locate' on %site plan) � +,�'R7,��;�,'.• ��;� �.. t. depth below grader C t r ' .'e'. material of construction: �` concrete •••_metal FRP other(explai dimensions: � _ �' M✓ /D zV 5 sludge depth .A_� distance from top of sludge to bottom of outlet tee or baffle scum thickness distance from top of scum to top of outlet tee or baffle ^n distance from bottom of scum to bottom of outlet tee or baffle Comments: (recommendation for pumping, condition of inlet and outlet tees or baffle! depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, recommendations for repairs, etc. ) d T AJ - ,V TAi f 1 DISTRIBUTION BOX: .. (logate on,site plan). Kf 6 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 for repairs, etc. ) PUMP CHAMBERS , ,w. „„, .. *,.,. ,.. , .....,.. . . . (locate on site plan) a�';: ,;+• ' •t • , ,,;.,7, .,` ; � ; �'.� is t. , ` . pumps in working order,"yes or no Comments: < . (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs,etc. ) SUBSURFACE"'SENAQE''DISPOSAL 'SYSTEM INSPECTION FORH PART B '''''BYSTEI4" 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, bepresent,','explain: Type leaching pits '.and number / /ado -2,4-IT 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 ponditig, condition of vegetation, recommendations for maintenance or repairs,etc 42, - t s a2 Y CESSPOOLS... (locate ,.,on „site.,Pl.an) 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+ pumpedsras'; part' of inspection) Comments: _. :...* .. ....., . (note condition of soil, signs of hydraulic failure, level porting, condition of vegetation, recommendations for maintenance of Pp :,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, recommendations for maintenance or repairs,etc. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 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? W". Discharge or ponding ;of effluent to the surface of the ground or surface waters? Al ' Static liquid level in the distribution box above outlet invert? _ Liquid depth in cesspool , <6" below invert or available volume< 1/2 flow? Required pumping 4 times or more in the [last ear? q P P g Y 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? // 'within 50 feet of a,.-surface,,water2a �. N � yt ` ,„ �• tr within . 100 feet of a` surface water supply or tributary to a surface water supply? • �� , ',, fir;; within a Zone I of a public well? A within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, the SAS) ? ' / ran`iFiyi#�,}�ran.1°,iy+;.#�:a., - •• - . . N i within 50 feet of a . private 'water: supply well? less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis? , has been analyzed to be acceptabler�at ' for coliform hacterka Qlm Fwj is c Na• , ror. tq > )) Tc., !� ° TRg,�, [ F� r f # i a y s14 F° (4 d °°� .. r; ,,,• Gt w, r d6 a -' 't ,.s' e { �,, l 1y r ' t a� £ rv:{^ T xa''�3-'r �a.i"" "' 'b rT k`. r �� ''h� hs'+�.a3%'`��"'A• is�t'+s i � _- -_ _._ .. - -.�-.d�e.•..�.`«.«. ..�=..''.`...c•»...- �...7:,Y -,r+,3:k« 4 s_-i.-_.`fir ..,er.:x h ;�.as.0 x. , 1] 4Mv3 SUBSURFACE SEWAOEgDISPOSAL SYSTEM INSPECTION FORH PART B ;, ;; t8Y8TEM NFORHATION. ,,00ntinued ` r •' i., :Sy aY•r,��� p,,,��'�' �p'd'Mt�r�lN'$f's.��3�'�r "''T�.»F2,��1:1( 7' 4` r. SKETCH OF SEWAGE DISPOSAL SYSTEM: : co include ties to at least two permanent� references ylandmarks or benchmarks locate ,all -wells,,within . l001.+' ' '�r /?raai" ?s 0 ; .t `^L r , ,.F: •;',C 'r tk, 4��.�+' �'.rrt w. � - it 4- z.. . t, 1 J.1..q{J �i M1: ' 1•�F� .91 • Est � �;,3 C1?Fr„'r'"tr '�i,1. ?re,MtJ•;� 'f! `r .'+Pi . .,.. i.. t r,.j-, ,.•g+�;'. .� .,'`+< w tjl r j^.1 Y•as S` �,.n,... ° �i (ir... .;ltpl•. �. J t 3 _. , ` +' +� r:t''. !, i ! °Ci/���:A��.* d�`�'J.i'4r�•?Jut �,w�� _�t •i(,j', t r' r: - i , ,� _ 0 � 'I17;ti��fd' s• a'r 7• r n • DEPTH TO GROUNDWATER 6Y -depth to groundwater ' E q;�s"A,�yrr �+tf5���rJft1''�8`S'G.*�4�J ��'►.4A�S.�bt��«'+�x; u: •TJ`•�r r �. . .•a�,r 'i"�s' •� . method of determination or approximations " SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORK PART D ,;:.CERTIFICATION . Name of Inspector 7�0 Company Name BousF«t-V5 �1+r SEaLv�e� . Company Address ' 4'S/ aeT 6� � S,a-.ww i e`,/ MFWS- 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: i/ 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 l � ,�� y 1 � 9s• . ; Original to system owner <: Copies to: Buyer (if applicable) ;. Approving authority 1 BOUSElELD SANITARY SERVICE 17 Burbauk- Street �+ Sandwich,Massachusetts ������ 02563 Name x!!/,�/l �/� P ---- _. Seger Permit No. � Location: Builder's Name and Address Date Pexm.it Tasued: /iZ- L Date Compliance Issued: 2/ 3 A 5/t-/A� _ __ a G.�/�%� _�___ �� ` �'e C�"/�vo i s� FER THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH UV e•�-1 �Z�� OF..................................... ............................................. A lirFation for Disposal Works Tonstrurtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Dispos System at: % S �- �'a ur�� La�� /lj//S ....._•--- t'.t l ?,-/ . ,1�.✓��v�------------------------------- ..---._... --- ocation-Address ....1.... . ,1...................................... ......own r ?dirrr a i. ✓ Nf (L9/C G �g Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms---........ ..........•...............Expansion Attic ( ? Garbage Grinder ( ) PL4 Other—Type of Building .. ?' -.-.... No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures ------------------ •----....- . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter----............ Depth................ Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-_----------------- Diameter......--.---.--..... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by................................:...........••-•--•-•---------._....•---.. Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water..---.---..........----. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-------................. .................•--.......-•-•--•-•----••---••-••••-••••--........--•..................-_._.............-•----••-••-.......•..._......---------•------.--•-- 0 Description of Soil....................................................................................................................................................................... W U ---------------------------------------------------- •----------------- •------------------------------------------------------------------------------------------------- •---------- ------------ •-------- W ---------------------------------•-••-••--•------------•----------------•--..........-------------------••••---•-----------------•-•--------------------------•--•-••------...-••---••-•••--------- UNature of Repairs or Alterations—Answer when applicable................................................................................................ -----•-----•--------•-•-•-----------•-••-•--••---------•--••----------------------------------•-•-•---•-------------------------------------••••.•••--•••-•--••--------•--•••-----------..........--•--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in ;D, ntil a Certificate o�C p ' has been issued by the board of health. Si -d---. _ --Id -- - . ----•--- APPlicationApprove B -- --- ��_ __.--•---......-•-••----------------••--•----•-•-•--••---•--• ....---• �... .............................. Date Application Disapprove or the following reasons:-----•-------•-•-•--•------••••---------------------••--------•----•--------•-••---••-----••-•----••-........._ ....-------•---••---•--•....-•--•-••-------------•-•------------•---•-••-•-••------•------•---•------------•••••--------•--••-•------•------•---•----•-••---------------------------- Date PermitNo.........................•---•-------------------•-----. Issued_....................................................... . Date No..............::_. FEs......--..................... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OFHEALTH ..............................._..----.....OF................I........---..--........ .......................................... Appliratiou for Bispvii a1 Works Tnnitrnrtinn rrntit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: k L t'q , s'�' >i 1 i s'r rr / ._•---•--o.z:f�............ .. :..t....-- -•-••-......-•-•----•--•---------- --••--•--•---•-- ------••••--•---........ ..........-----...._......_..--•--------- ocation-Address / of No� Own r Addrt?ss W ....................... y .`.j. ... �?!,� !`S ':. a? lt.A.t� t : _ _, r� ? ...�)2 r°-,� °" ....... ¢: �. � Installer '''� - ,/ Address U Type of Building '�- --.,. Size Lot............................Sq. feet, -«.. Dwelling—No. of Bedrooms.__........a.-•__________________________Expansion Attic � Garbage Grinder ( ) Other—Type of Building '------- No. of persons....................... ..... Showers ( ) — Cafeteria ( ) FI Other fixtures ... d •----•.---•--•----------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width...............=;Diameter................ Depth................ x Disposal Trench—No- -------------------- Width.................... Total.Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet........:........... Total leaching area..................sq. ft. Z Other Distribution bdx'( ) Dosing tank Percolation Test Results Performed b Y•`' a Y------------------•------•-------=,.;:----------•----------------=------:_ Date........................................ Test Pit Nd:{ 1.....: .......minutes per inch Depth of Test•-Pit! ............. Depth to ground water_.---........._.._.__. LEI Test Pit No:'2............:':_.-minutes per incht Depth of Test Pit.................... Depth to ground water........................ ---- ---------------------* •..... •---------------------- _--------------- _-------•-•----------------------------------------------------------- ---••- ODescription of Soil----••--•-------••------•---------------------------••-•----•---••-----•------••----------:=------------•--------------••---•-------------............................. x ,. W ---------------------•-•-•-••------•---•-------•------------....--•-•---••--•---•----•-...-•-•--•--•----------------------•----------------------••------••-......-------------------------------------- UNature of Repairs or Alterations Answer when applicable.-.............................................................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITI1Z- 5 of the State Sanitary Code— The undersigned further agrees not to place the system in o tion until 'a/Cerrtiificate *C 1• ee has been issued by the board of health. / �,. Sign ...61011.4 l Application Approve y_� _ .............................................................. ••.._...... �r/ f -------------- / Date Application Disapproved��r he following reasons-------------------------•-----------•-----------------------------------------------------------------•----..._ ..........................••---------•--1....._....----------------------------------------••-----------•--....._..---•---•------------------•---------•--------•--------•------------------------------ Date Permit No................................................... Issued..---•---•---•------.. Date ------ THE COMMONWEALTH OF MASSACHUSETTS ^ � BOARD OF HEALTH '.:.:.. ..................OF. e, nAvt� ................................ C�rrtifiratr of Toutph atta THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) r__b .-• �'Y ----------•-•-••-•---- - t`� < t Inst311er at`'` r `� � =`' --------------------I_�r" - i �. / /aesc _- ------------- -- _.,_ has been installed in accordance with the provisions of TITLE 5 f The State Sanitary Co 'Tied in the applica,fion for Disposal Works Construction Permit No..__�r�.__�___��.,�..._...___. dated_�'_� .4-0................. THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTWV0 S A GUARANTEE THAT THE SYSTEM'WjiL FJJNCTION SATISFACTORY. DATE... ..11.__!t-- ------------------------------------•.......•---__--_. Inspector. . -- ---•-- ....•--•-----.......---••------•-•----•-------•--•-•-...........-- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............................OF........................ , N .. .r. ` FEE.., ............. Disp or 1 nrks Tnnotrnrtinn rranit Permission-,$ hereby ranted- , to Construct O or�R pair (r` an Individual"S'ewage Disposa},>ystem � Fr�L"- ........... f Street .. .r+y'�C —t. .. c� as shown on the application for Disposal Works Construction Permit Ne���;_..-.t]_"f_`�.._ � ________________________ ................... ............................................/�+}► � f Board of ealth DATE----------------------p--(--- ---...-------•-••------•----•----------•--•-•----. . FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS t , ... «... .Y' +:. t>k '"I F... ,. R.. t '} ..., ,x>An n ._ ...c , ., .Vv, .:4 ^S.. "94, §1♦. ...1.Y7 ...... . :. .< .o ,. x. .. ;.. .. ,. .. .. S.. ♦.. ._. .. ..».,v. , _: '. F" of .. t'. .... ._. .: .,. 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S teoi7t-iG t Zt7J le 0 ltict 6 df e.cad ° • q �r a p j f" e ° ° S7+o.-7a/'/ 0 o �10:5 /0.S The rc�+is7`-�recs/ rsr-rge�,eer +/�os� Stump e2^Cle 4trS ors 7Lhese ✓ 1�•/ �- Mi9.E`'S7-0 i ,sh�z// , +� t e S�G+rrsibie for fh e I_Z14G4�- "3= - / svpervisic3r7 czr»1 cer�fifiGca icara of ©r : 11-1 Or,) - 7 CH ,-7 Q/�,I C- sc" ,/"C• G c�r75�"`!^tJG 7`it�r7 rr� 57`t�i c 7` a �c orrs�a r7 c e Lvi?`h 7417CSre Vic+/urns Lvt�7�'t7 oc1oprt Ve'ci 6Y 7�h� coo ve�'rry�'n yt ;6oc�rc�/` �f hec�./•�'��r. b its t7 : O 7" 9/ -` --- f�.q/U ZS 0 Cam.- .72 1"Ca• �a' S T.Gi 7—C_- S t•, &,R L 7-H O�At r'JAMES�+ c�c ccf rr ca.� n 9 e`i�►e r�'t-7 Qp Y ? toto �� 4, 1 c"r_V2 t+e-Y, `C'*4A'C "t NEZE. A �xca -v.r�tJ,+S d •-S W �=aYS t` t�1 S wt'T1-i t e s Z e�eA i') cam TN►S t_.ca;. f J , n � ' ,. fit\•� r, �,`` } , a^� „ " :, Y.. .:. ..`;:. ,. .._::,:.,.,..«_,...,,. ,.>... ,. ,. '..:.:. _>:sx.. , s .. .. ..mu_�._}r..�...-S:Yeww.. •,..t,:b x ..-.....-.la ..,. at. ,. 2 , ,