Loading...
HomeMy WebLinkAbout0042 MILL POND ROAD - Health j. 42 Mill Pond Road 1Vlarstons Mills r A= 063 — 036 TOWN -�ppOFnBARNSTABLE t� L•�°A 11ON VA\\\ �U�pl SEWAGE # '+ ,aLAGE NftlVST',, ry VJl t 1` ASSESSOR'S MAP & LOT 3(o INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY MO U C�W , LEACHING FACILITY: (type) 1.T (size) NO.OF BEDROOMS BUILDER OR OWNER DATE: ��2��S�L COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater.Table y 8`V 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) N Feet Fur:ushed by �� C�� To6t �x"OJO Z L1 tq- t2- a.�l k3 39 r 63- 36i 3 INS- 55' gS` Sol A COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION M A� Q David B.Mason,R.S,Certified Title V Inspector,508-833-2177 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION I �l Property Address: 42 Mill Pond Road,Marstons Mills,MA C� Owner's: Ciampa Owner's Address:30 Amberwood Drive,Winchester,MA 01890 Date of Inspection:July 8,2010 Name of Inspector: (please print)David B.Mason Company Name:—N.A. Mailing Address: 4 Glacier Path East Sandwich,MA 02537 Telephone Number: 508-833-2177 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:. _ _X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority ails Inspector's Signature: Date: to The system inspector shall submit a copy of this inspection report to the Approving Au ority( oard of Health-ar DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments: System as inspected appears to have operated based on occupancy level. Increase in occupancy may cause hydraulic failure.The information as identified represents only the condition of the system on July 8,2010 at 1 PM. ****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. I ,� �/ v Title 5 Inspection Form 6/15/2000 page 1 7 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:42 Mill Pond Road,Marstons Mills,MA Owner: Ciampa Date of Inspection:July 8,2010 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _X_ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced (THIS IS REQUIRED TO BE COMPLETED) 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: OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Page 3 of 11 PART A CERTIFICATION(continued) Property Address:42 Mill Pond Road,Marstons Mills,MA Owner: Ciampa Date of Inspection:July 8,2010 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: The primary cesspool is not a typical configuration for a cesspool. It appears to be a pipe cylinder with an inlet pipe and outlet pipe with tee connected to a pre-cast 4'deepx6'diameter leach pit with stone. Permit on file with the BOH for the pre-cast leach pit. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) e Page 4 of 11 Property Address:42 Mill Pond Road,Marstons Mills,MA Owner: Ciampa Date of Inspection:July 8,2010 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to 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''/z 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 _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _X Any portion of 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. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] _No_(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface 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. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST 4 Page 5 of 11 Property Address:42 Mill Pond Road,Marstons Mills,MA Owner: Ciampa Date of Inspection:July 8,2010 Check if the following have been done.You must indicate"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_ _ Were any of the system components pumped out in the previous two weeks? X_ Has the system received normal flows in the previous two week period? _X_ Have large volumes of water been introduced to the system recently or as part of this inspection? _X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ _ Was the facility or dwelling inspected for signs of sewage back up? _X_ _ Was the site inspected for signs of break out? X_ _ Were all system components,excluding the SAS,located on site. _X_ _ 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? _X_ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _X_ _ Existing information.For example,a plan at the Board of Health. _X_ 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(3)(b)] OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Page 6 of 11 F PART C SYSTEM INFORMATION Property Address:42 Mill Pond Road,Marstons Mills,MA Owner: Ciampa Date of Inspection:July 9,2010 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):4 (per assessors records Number of bedrooms(actual):4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): (440 gpd capacity) Number of current residents:_varies_ Does residence have a garbage grinder(yes or no):NO(Not Allowed) Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required]Per owner Laundry system inspected(yes or no):NA Seasonal use: (yes or no):Yes Water meter readings,if available(last 2 years usage(gpd)):Private Well Sump pump(yes or no)m e :No Last date of occupancy: (current) COMMERCIAVINDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Barnstable Health Department Was system pumped as part of the inspection(yes or no): yes If yes,volume pumped:_1000 gallons--How was quantity pumped determined? Reason for pumping: Requires maintenance pumping TYPE OF SYSTEM _X Septic tank,distribution box,soil absorption system(2- 10000 gallon leach pits with 2' stone) _Single cesspool _Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information:Installed 1999 Were sewage odors detected when arriving at the site(yes or no):NO OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Page 7 of I 1 PART C SYSTEM INFORMATION(continued) Property Address:42 Mill Pond Road,Marstons Mills,MA Owner: Ciampa Date of Inspection:July 8,2010 BUILDING SEWER(locate on site plan) Depth below grade:Approximate; 14 Inches Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line:_NA Comments(on condition of joints,venting,evidence of leakage,etc.): Appears in good condition. No evident leakage. SEPTIC TANK: N.A.(locate on site plan) Depth below grade: 10" Material of construction:X_concrete_metal_fiberglass_polyethylene_other(explain)_ If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Typical 1000 gallon tank Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle: 14" Scum thickness:2.5 inches Distance from top of scum to top of outlet tee or baffle: 15" Distance from bottom of scum to bottom of outlet tee or baffle: 12.5" How were dimensions determined: Actual measurements with tape and scour stick. Condition of tank(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.) Concrete baffle in place acting as tee.,Effluent level with outlet pipe. GREASE TRAP: N.A. Depth below grade: Material of construction:_concrete_metal_fiberglass__polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle_ condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Page 8 of 11 ` PART C SYSTEM INFORMATION(continued) Property Address: 42 Mill Pond Road,Marstons Mills,MA Owner: Ciampa Date of Inspection:July S,2010 TIGHT or HOLDING TANK:—N.A.—(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:_X_(if present must be opened)(locate on site plan) Depth of liquid level even with outlet invert: liquid level even with outlet pipe 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.): no indication of solids carryover. D-box 24 inches below grade._Effluent is level with outlet pipes. PUMP CHAMBER:,(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM e Page 9 of 11 PART C SYSTEM INFORMATION(continued) Property Address:42 Mill Pond Road,Marstons Mills,MA Owner: Ciampa Date of Inspection:July 8,2010 SOIL ABSORPTION SYSTEM(SAS): X_(locate on site plan,excavation not required) If SAS not located explain why: Type _X_leaching pits,number 2 1000 gallon leach pits _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, etch Probed stone area. No sign of hydraulic failure. No damp soil.No excessive vegetation growth. 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 or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:—N.A._(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.): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Page 10 of 11 PART C SYSTEM INFORMATION(continued) Property Address: 42 Mill Pond Road,Marstons Mills,MA Owner: Ciampa Date of Inspection: July 8,2010 i 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. Note: Well is 100 feet from existing leaching. Well located front left per owner Rear of AnnaP A B Deck Deck ❑ A-1 12'-6" 1 A-2 19' A-3 38' A-4 45' A-5 35' 2 B-1 24' B-2 28' ❑ F3] B-3 36' B-4 48' B-5 50' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM in Page�11 of 11 PART C SYSTEM INFORMATION(continued) Property Address: 42 Mill Pond Road,Marstons Mills,MA Owner: Ciampa Date of Inspection: July 8,2010 SITE EXAM Slope Surface water Check cellar (crawl space) Shallow wells Estimated depth to ground water_15_feet Please indicate(check)all methods used to determine the high ground water elevation: _X_Obtained from system design plans on record-If checked,date of design plan reviewed: _X_Observed site(abutting property/observation hole within 150 feet of SAS) _X_Checked with local Board of Health-explain:Recent Test Holes, Existing engineer records with BOH _X_Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Utilized existing site design information on file with the Board of Health. Additionally,existing site and abutting site topography does not indicate ground water to be within 5 feet of bottom of leaching facility. No. .206 2 7 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes pplicatiou for �N!5potal �&p5tem (Lon0truction Permit Application for a Permit to Construct O Repair(Upgrade O Abandon O ❑.Complete System Individual Components Location Address or Lot No. '5;J ,Wlee 40'01o^'6 G? Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 4 e5 3; 3 d�� Oj, Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. (7>­� Ce`6zz,�z�� ��y�34r Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building d�C''.f'.. No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date -"._/p'O> Application Approved by Date i 2.(o—o 7 Application Disapproved by: Date for the following reasons Permit No. 2od 7 ^ 57�7 Date Issued l a —/d D 7 1 Fee r No. 2U0 7 0 Q y THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Application for aigpogar 6pgtem Con0truction Permit Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) El Complete System l Individual Components Location Address or Lot No. y9 /W/Le &0'0/"4 40 Owner's Name,Address;and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: s Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building �c e�`.f'. No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed ' Dateev— Application Approved by Date /2 °^v 7 Application Disapproved by: Date for the following reasons Permit No. 2 ch 7 -- 0-7 Date Issued —————————— ------ ---� --- -_------ THE COMMONWEALTH OF MASSACHUSETTS a� l BARNSTABLE, MASSACHUSETTS �' boy (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed (; )1 Repaired ( v) Upgraded ( ) Abandoned( )byLTi at has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. J O U-7` S.S 7 dated (.2/d-07 . Installer Designer #bedrooms u] Approved design..fl�ow n/f 4- gpd The issuance of this permit shall not be const.tueed.as a guarantee that the system vh1l function ag'desig—ne'a• Date N Inspector : —————————c————————---------------------------- No. //� Fee Q v � THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS 1=igPO9;a1 *pgtem Congtruction'permtt Permission is hereby granted to Construct ( ) Repair ( Upgrade ( ) Abandon ( ) System located at y�- ��/G G' /�OA.,p „fj/�. �f� /J7, and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Cons ction must be completed within three years of the date of t is pet Date I.L lu b Approved by ✓�`� C � __�Iow ' COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS r DEPARTMENT OF ENVIRONMENTAL PROTECTION Y I ti David B.Mason,R.S,Certified Title V Inspector,508-833-2177 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 42 Mill Pond Road,Marstons Mills,MA Owner's: Ciampa C5--:5U Owner's Address:30 Amberwood Drive,Winchester,MA 01890 Date of Inspection: December 8,2007 Name of Inspector: (please print)David B.Mason Company Name:—N.A. Mailing Address: 4 Glacier Path East Sandwich,MA 02537 Telephone Number: 508-833-2177 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a IMP ' approved system inspector pursuant to Section 15340 of Title 5(310 CMR 15.000). The syste : gam; X_ Passes c-) r� Conditionally Passes co _ Needs Further Evaluation by the Local Approving Au :ty Fails , Inspector's Signatuzl;� UbL Date: �� 1,007,cn r- rl M The system inspector shall submit a copy of this inspection report to the Approving Authority(Boa d of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments: System as inspected appears to have operated based on occupancy level. Increase in occupancy may cause hydraulic failure.The information as identified represents only the condition of the system on December 8,2007 at 9:30 AM. Maintenance pumping is required. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 r Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 42 Mill Pond Road,Marstons Mills,MA Owner: Ciampa Date of Inspection: December 8,2007 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced (THIS IS REQUIRED TO BE COMPLETED) 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: Title S Tnanartinn Rnrm Aii VIAM 2 Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 42 Mill Pond Road,Marstons Mills,MA Owner:Ciampa Date of Inspection: December 8,2007 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: The primary cesspool is not a typical configuration for a cesspool. It appears to be a pipe cylinder with an inlet pipe and outlet pipe with tee connected to a pre-cast 4'deepx6'diameter leach pit with stone. Permit on file with the BOH for the pre-cast leach pit. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Title S Tnenartinn Fnrm 0;/1';i')nnn 3 Page 4 of 11 PART A CERTIFICATION(continued) Property Address: 42 Mill Pond Road,Marston Mills,MA Owner:Ciampa Date of Inspection: December 8,2007 D. System Failure Criteria applicable to all systems: Y PP Y You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to 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''/z 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 _ _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of 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 1 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. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] _No_(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface 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. Title 1;Tnen,-rtinn Rnrm All Vlnnn 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 42 Mill Pond Road,Marstons Mills,MA Owner:Ciampa Date of Inspection: December 8,2007 " Check if the following have been done.You must indicate"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 _ Were any of the system components pumped out in the previous two weeks? _X Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS,located on site. _X_ _ 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 ? _X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X _ Existing information.For example,a plan at the Board of Health. X_ 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(3)(b)] Titles S Tnenartinn Rnrm All V10(10 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 42 Mill Pond Road,Marstons Mills,MA Owner:Ciampa Date of Inspection: December 8,2007 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design :4 r assessors records Number of bedrooms(actual):4 DESIGN flow based on 310 15.203 (for example: 110 gpd x#of bedrooms): (440 gpd capacity) Number of current residents:_varies_ Does residence have a garbage grinder(yes or no):NO(Not Allowed) Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required]Per owner Laundry system inspected(yes or no):NA Seasonal use: (yes or no):Yes Water meter readings,if available(last 2 years usage(gpd)):Private Well Sump pump(yes or no):No Last date of occupancy. (current) COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no):— Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER{describe): GENERAL INFORMATION Pumping Records Source of information: Barnstable Health Department Was system pumped as part of the inspection(yes or no): yes If yes,volume pumped:_1000_gallons--How was quantity pumped determined? Reason for pumping: Requires maintenance pumping TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system(2- 10000 gallon leach pits with 2'stone) _Single cesspool _Overflow cesspool _Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed 1999 Were sewage odors detected when arriving at the site(yes or no):NO OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS TiflP 5 Tncr%petinn Fnrm (,/1 VlfNlfl 6 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:42 Mill Pond Road,Marstons Mills,MA Owner:Ciampa Date of Inspection:December 8,2007 BUILDING SEWER(locate on site plan) Depth below grade:Approximate; 14 Inches Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line:_NA Comments(on condition of joints,venting,evidence of leakage,etc.): Appears in good condition. No evident leakage. SEPTIC TANK: N.A.(locate on site plan) Depth below grade: 10" Material of construction: X_concrete_metal_fiberglass__polyethylene_other(explain)_ If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Typical 1000 gallon tank Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle: 14" Scum thickness: 2.5 inches Distance from top of scum to top of outlet tee or baffle: 15" Distance from bottom of scum to bottom of outlet tee or baffle: 12.5" How were dimensions determined: Actual measurements with tape and scour stick. Condition of tank(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.) Concrete baffle in place acting as tee.,Effluent level with outlet pipe. GREASE TRAP: N.A. Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): T;tla S Tncrv-rt;nn Rnrm All snnnn 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 42 Mill Pond Road,Marstons Mills,MA Owner:Ciampa Date of Inspection: December 8,2007 TIGHT or HOLDING TANK: N.A._(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity. Gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: X_(if present must be opened)(locate on site plan) Depth of liquid level even with outlet invert:liquid level even with outlet pipe 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.): no indication of solids carryover. D-box 24 inches below grade._Effluent is level with outlet pipes.Dbox is decayed and was replaced as part of inspection. Riser was added to within 6 inches of grade. PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Titles S Tnanc+rtinn Fnrm 6/1 V'Wn 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 42 Mill Pond Road,Marstons Mills,MA Owner:Ciampa Date of Inspection:December 8,2007 SOIL ABSORPTION SYSTEM(SAS):_X (locate on site plan,excavation not required) If SAS not located explain why. Type X leaching pits,number 2 1000 gallon leach pits _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, etch Probed stone area. No sign of hydraulic failure. No damp soil.No excessive vegetation growth. 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 or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:_N.A._(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.): Title S Trncnartinn Fnrm All Vlnnn 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 42 Mill Pond Road,Marstons Mills,MA Owner:Ciampa Date of Inspection: December 8,2007 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. Note: Well is 100 feet from existing leaching. Well located front left per owner Rear of Hn11 RP. Deck ❑ A-1 12'-6" A-2 19' A-3 38' A-4 45' A-5 35' B-1 24' B-2 28' ® B-3 36' B-4 48' B-5 50' Titles i Tnenr>rtinn Fnrm ail si')nnn 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 42 Mill Pond Road,Marstons Mills,MA Owner:Ciampa Date of Inspection: December 8,2007 SITE EXAM Slope Surface water Check cellar (crawl space) Shallow wells Estimated depth to ground water_15 feet Please indicate(check)all methods used to determine the high ground water elevation: _X_Obtained from system design plans on record-If checked,date of design plan reviewed: _X_Observed site(abutting property/observation hole within 150 feet of SAS) _X_Checked with local Board of Health-explain: Recent Test Holes, Existing engineer records with BOH _X_Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how,you established the high ground water elevation: Utilized existing site design information on file with the Board of Health. Additionally,existing site and abutting site topography does not indicate ground water to be within 5 feet of bottom of leaching facility. Tithes';Tnen,-rtinn Pnrm (,/1 S/)nnn 11 Town of Barnstable y FIKE Regulatory Services STABLE. Thomas F. Geiler, Director EMASS ,,•0� 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. 49 . CO\I\IONWEALTH OF NLksSACHUSETTS h - EXECUTIVE OFFICE OF ENVIRONI4E\TAI SIRS DEPARTMENT OF ENVIRONMENTAL PRO T ON �r ONE X%INTER STREET. BOSTON NL4 02106 (61,) 29`L:i:iU 1999 TRL' COXE �Se,retan s ,;RGEO PALL CELLliCCI ' I)d,�q B. STRL'HS Governor r, Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A V"V 2IP CERTIFICATION ` c Property Address: � � Name of Owner f�Ir'(t %R*, t'A ��5 Address of Owner: Date of Inspection: \Z\ ,�+ Name of Inspector:( ease Pn )! [ c-4 d e I 1 am a DEP approved system inspector pursuant to Section 15.[340 of Title 5(310 CMR 15.000) m Copany Name: 14&& r r u % E F . . %r- in±C - Ma&V Address:.? _i G4- Cl Tetepfwne Number: sp�-2 L E /4- - e_o CERTIRCAT10N STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails inspector's Signature: Date: Lk�?Acic_% The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty (30)days of completing this Inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS revised 9/2198 Page tofIt `�'Printed on Recycled Paper 1. r t• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CER TIFICATION (continued) , R' 'roperty Address: Jwner: Date of Inspection: r- + INSPECTION SUMMARY: ,Check A, B, C, o/ D: A' SYSTEM PASSES:./ 1 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: 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. es no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined",explain why not. Indicate ,1 Y _ 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. _ Sewage tiackup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)_ or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed revised 9/2/'98 P>pZ-of.0 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: 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 th 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 R 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SA 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 mars . 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SU PLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SA AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system(SAS)and he 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 AS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the AS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and th SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for colif rm bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence f ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: D. SYSTEM FAILS: You must indicate either "Yes" dr "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 identifiedI',Oelow. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No . _ Backup of sewage in't.o facility or system component due to an overloaded or clogged SAS or cesspool. _ Discharge or ponding o.-f 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. _ Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less-than`.100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for <coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: 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 the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) \ The owner or operator of any such system shall upgrade the system in accordance with 310,CMR 15.304(2). Please consult the local regional office of the Department for further information. L revised 9/2/98 Page 4of11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes 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"mmal flow " C rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. X _ The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: k _ Existing information. For example, Plan at B.O.H. Determined in the field(if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)) The facility owner (and occupants,if different from owner) were provided with information on the proper maintsnan"-of SubSurface Disposal Systems. revised 9/2/98 Page 5ofll SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION 'roperty Address: Y"l(I( poij Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: -Ayb g.p•d./bedroom. Number of bedrooms (design):Q Number of bedrooms (actual):OL Total DESIGN flow q4 C Number of current residents: Garbage grinder(yes or no): P IN Laundry(separate system) a or no):_,: If yes, separate inspection required Laundry system inspected es r no) Seasonal use (yes or no): Water meter readings, if available (last two year's usage (gpd): Sump Pump(yes or no)._ Last date of occupancy: 14 gb$.y`lA COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: qpd ( Based on 15.203) Basis of design flow Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no) #10 1 l If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM Septic tank!distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records,if any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other p APPROXIMATE AGE of all components, date installed lif known)and source of information: Sewage odors detected when arriving at the site: (yes or no) tAZ revised 9/2/98 Page 6orll SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'roperty Address: 1 f m t ` �a Owner: Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade:_ Material of construction: _cast iron_40 PVC_ other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK: (locate on site plan) Depth below grade:_ Material of construction: _concrete_metal _Fiberglass _Polyethylene_other explain) If tank is metal, list age_ Is.age confirmed by Certificate of Compliance._ (Yes/No) Dimensions: Sludge depth: Distance from top of` sslludge to bottom of outlet tee or baffle:_ Scum thickness: \ - t( : Distance from top of scum to top of outlet tee or baffle _ Distance from bottom of scum to bottom of outlet tee or baffle: \�t' How dimensions were determined: 'omments: (recommendation for pumping, c diti n of.inlet and outlet lees or baffles, depth of liquid level in rela 'on to outlet vertt,uctUral' tegrity, evidence of leakage etc.) (A j v 1 G GREASE TRAP: (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass _Polyethylene_otherlexplain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (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.) revised 9/2/98 Page 7ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ` SYSTEM INFORMATION (continued) 'roperty Address: Owner: Date of Inspection: TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade:_ Material of construction: _concrete_metal_Fiberglass_Polyethylene —other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order: Yes _ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:"dL (locate on site plan) (� Depth of liquid level above outlet invert:l SL'-'(wk UvT�� Comments: - (note if I el and distribution i e ual, eviden of solids carryover, a Bence of leak g`into Cr t�oytf�box, etc.) 7 � l e� PUMP CHAMBER: U'J (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber,•condition of pumps and appurtenances, etc.) revised 9/2/98 Page 8ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 4opeRy Address: l Owner: Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): S (locate on site plan, if possible: e,xcava ion not required, location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number: leaching chambers, number:_ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: �Inolendition o�soil igns of hydraulic�ft0lure, Ievelponding,�dampoil,.c dition ve tg� ation, etc.) f p CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: )epth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: E (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) revised 9/2/98 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) ")roperty Address: lwner: Date of Inspection: 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) a b � $ t t ;013 5 f ,fig, revised 9/2/98 P4c10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C �Q SYSTEM INFORMATION (continued) roperty Address: Owner: Date of Inspection: NRCS Report name -- — --- Soil Type_ — -- --- -— Typical depth to groundwater _ USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope w-NO Surface water tld Check Cellar Shallow wells pto 1 Estimated Depth to Groundwater"X Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record 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 Used USGS Data Describe how ou established the High Groundwater Elevation. (Must be completed) revised 9/2/98 Page 11of11 L0,' A ION SEWAGE PERMIT NO. /Y,// 10�� 063 VILLAGE INSTALLER'S NAME & ADDRESS � h 119a e B UI'LDE R OR OWNER ��/ DATE PERMIT ISSUED D 0MPLIA I ED ATE C NCE SSU !. \ � �• .. �, i ,.� �N � ►� �. '� ' � � i �� w >;� � a ,� E�� , '� ti .' :� -��� „ e i �� ���I � �1? '•d e ,�;�,. S-,.. No.. s Fss ..... ---......... r ti' . THE BOA R OF COMMONWEALTH F TS HEALTH 1 H ...............OF.......... ....�� P ... - ................... Apphration -fur Raposal Works Tomitrurtion Vleruiit Application is herebymade for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: t `3 ...........�`.:�.��1--��- _-. ..-R1 ......... •-----....Ns�\Qnna... \\s........hm ......... ca io •Add.ess or of No. t. r�------•..................... ........41 4 Z =�1&.... `c�.. ... .... �c O r dress Installer Address Q Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms._._ .. .................Expansion Attic Garbage Grinder (� aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Qa' Other fixtur s ............................... .. --------------------------------------------------------------------•.-.......-------------•---------------------- W Design Flow................�..._.._....._.©gallons per person per day. Total daily flow.._-------•---7.4�..._--.......gallons. tic Disposal Trench—No capacity --_` dth- Length Total Length idth------- Total leaching area-. Depth---------------- Disposal ft. Seepage Pit No.. .............. Diameter..l ....��Depth below inlet_.-__-._-_-_.-..-_.- Total achin •trea----..............sq. ft. Z Other Distribution box (� Dosing tank ( ) d� dab .T/' 76 — /C C 2 . Percolation Test Results Performed by------- ------------------------------------------------------------------ Date------------------------------------.... Test Pit No. 1................minutes per inch Depth of "Pest Pit.................... Depth to ground water........................ fZA Test Pit No.-2................minutes per inch Depth of Test Pit........_.-..-.-__-- Depth to ground water........._....---------. ------------------- t� ------- ------ . ---•----------------- ---- Description of Soil------ ---------------�J.."-A...-- ��------ic� ,?- � �- x ------------ c., - ---/r- -------------------------------------------------- ----------- .--- ---------------------------------------------------------------------------------------------------------------'--- U 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 b is ued by tthhee board of h lth. igned... . a--- 7—27�7.4 Application Approved By------------ - --- ----- --- ---`......• ... ------7 1,74.. Date Application Disapproved for the following reasons:----••----•-........--•-••-------------•------••........-----------......-•-------. .........---•----•---------. ...........................................•---•------------------------------------•--------------------------.-----•-------------•-----------------------•---•---------------------- ................. Date PermitNo......................................................... Issued........................................................ Date ----------------- --- - - r No.✓•••••.. ............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _.... . _. ... ..................OF..................................... ................................................... Applirtttion -for Dispoottl Norko Tonitrurtion Vrrntit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ----------------------------- •...... •-------------- •--------------- ••-•--------- ........---------- ••------------------------------------ -----••-------------------------------------- Location-Address or Lot No. ----------------------------•-••---••--••--••------------•--•-----................•••••••••••••••• ...................••---•...•-•••...............-•--•.....•-----•-••••........................••• Owner Address W I -- Installer Address Q TypeCwelling f Building Size Lot............................Sq. feet a —No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) p, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtur s ...................................................... W Design Flow............... ......................... per person per day. Total daily flow...............7--- — ___..........gallons. IY4 Septic Tank—Liquid capacity-------.....gallons Length................ Width................ Diameter______-._-.-.__ Depth---------------- xDisposal Trench—No-____________________ Width......... Total Length-------------------- Total leaching area....................sq. ft. Seepage Pit No..................... Diameter..l.. ...... 'Depth below inlet.................... Total leaching area.._...._...._....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) — ' 3- -7/- C aPercolation Test Results Performed bY-------------------------------------------------------------------------- Date---------------------------------------- Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_.-___-.__--_--..-.--._. f4 Test Pit No. 2-___-•--..._____minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ P4 ------•--- ---- -- ----------- Description of Soil-------------------- � r-a•` ��c1�2. f S_l�1 � �=- ----------- -� -- - -•--- --�•--••------ ---------------- -----------�--------....----•--•-•••......-•••-••---••• ••-••---•----•---------•-•••---- JL.t. _ ._ r .�. =----------------------------------------- �ii el U 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. igned.. .. --------•------------------••---•-----•--•-----•------.------•----- -------------------------------- Date Application Approved BY.........._ �f ..... !�.................. -------- ---k 7 Date Application Disapproved for the following reasons:....................................................................................•---... ......-••----- -------------•---•---------•-------•--------------------------•---•-------------•---•-------•------------•-----------------••------•-----------------------•-•-•--------.-----_---------•---------.----- Date PermitNo........................................................ Issued........................................................ Date tt THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEA ,TH .......1....C?" Lyt..............OF........ .-. .. .. . ....:.......................... (9rrtifirtttr• of 101.1,11mplittnrr TI IS IS TO CERTIF ; That'th "Individual Sewage Disposal System constructed l l or Repaired ( ) by ��Q /Q-E_- d--------------------•----.. ....--...... ---- ------------------------------ at ' 's =' 35 ---------- e ns filer has been installed in accordance with the provisions of Arje6le XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.�-7k_--_J_.2._�____-•--__._._- dated _.-.--_J -------- ..-e....._.._. THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUE© AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. ,,� DATE , 6------------ '�-=e ------------- - ................. Inspector...... .--- Y=+ .................... THE COMMONWEALTH OF MASSACHUSETTS ! � BOARDJF HEALT v / No.•. --•--• '. FEE/-_----•--••-....... �i��>a ttl porky-� � �trurtioat �rrmit Permission, is hereby granted. 1'. -t­-z--- ••----•-----------------------------• -••--------------.....-•-•------------•-----•----- to Constr et f or Repaj n ideal e , g Dispos '1 Systems/ S ,K /� ,� ! atNo.-• -- '-------- u ��`�1%._ __v im.. v�'`� t ............................................ Street as shown on the application for Disposal Works Construction Permit'Alo.........:......... Dated_ 7 .�. '<.�.......... -------- ----------! /."- - - - DATE.-----•..............•-•--..............................• ..................•. Board of Health FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS 1^ l a er +I , II at1 Q LC , "I 351 6• Area 1.00 - Ac. Propo s¢d S¢ p��t, sy �• � - ► 15Wga1 N i �xtS" tnC) We 1 Al 8 � 30. OA . At KINGSBURY L, p P 26101 d �jSTU SJ f C, 'F-, E7Rf ) Ei 0 PL.OT PL ,&Q OF Lr 4 -J O r 1 � � 4- n CL n l �� ce � �, �,¢ -�o u d �a i � �3 �► �t�J ST`��a L. I� ,A� Shown hereon t.s O-C-tUOJIy )Qc 4 ed on �e roue d and r C n o nn5 , +o of I Ta r� -Fca ; i ! I,A C ,C C �5caj¢, i - 40 ju€y . Z 19'7Co ' c u e� 5U ev eY t c�\� ered L&r�d ur r IZI oUTG Ca-A CO,, VAM