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HomeMy WebLinkAbout0020 ORIOLE LANE - Health L0A = ns Mills V 13.. 048• - -- - — -- — - - • Town of Barnstable Barnstable y�P °* Regulatory Services Department ei"a�I BARMASS.NSrAB •► public Health Division - m MARS. A 16± � �prF0 A`� 200 Main Street, Hyannis MA 02601 2007 Office.: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL #7011 0470 0001 4525 6829 May 24, 2012 Mr. William Reilly 940 Cotuit Road/Rte 149 Marstons Mills, MA 02648 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, Title 5. The septic stem located at 940 Cotuit Road/Rte 149 Marstons Mills MA was last P Y > inspected on 5/3/2012 by Patric T. Sullivan, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following: • System is in hydraulic failure. You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. ailure to repair/replace the septic system with in the deadline period will result in future enforcement action. PER O=cKean, RD OF HEALTH Agent of the Board of Health I Q:\SEPTIC\Letters Septic Inspection Failures or Future Eval\940 Cotuit Rd.,M M.doc Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments SVea 940 Cotuit Road (Route 149) Property Address William Reilly Owner Owner's Name information r uired f is Marstons Mills MA 02648 May 3, 2012 every page. Cityr town State Zip Code Date of Inspection . t 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. Important: A. General Information When filling out forms to the o computer,use 1.• Inspector. h.(/n only the tab key to move your Patrick T. Sullivan cursor-do not Name of Inspector use the retvm key. Ready Rooter, Inc. Company Name -ball P.O. Box 371 Company Address } Sandwich MA 02563 e' Cityrrown State Zip Code 508-888-6055 SI 12843 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 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ❑ Conditionally Passes r ❑ Needs Further Evaluation by the Local Approving Authority - May 9, 2012 In or's Signature Date r" The system inspector shall submit a copy of this inspection report to the Approving Authority( 'card of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. UIV t5ins•11)10 (- TideVmlspection Form:Subsurface Sewage Disposal System•Page 1 of 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form,-Not for Voluntary Assessments 940 Cotuit Road (Route 149) Property Address William Reilly Owner Owner's Name information is Marstons Mills MA 02648 May 3 2012 required for Y every 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: B) System Conditionally Passes: ❑ One or more system components as descri ed in the "Conditional Pass"section need to be replaced or repaired. The system, upon pletion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not dete fined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 ye rs old*or the septic tank(whether metal or not) is structurally unsound, exhibits substanti I infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tan is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass insp ction if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the to is less than 20 years old is available. ❑ Y ❑ N ❑ D(Explain below): t5ins•11M0 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 940 Cotuit Road (Route 149) Property Address William Reilly Owner Owner's Name inform.uir for req Marstons Mills MA 02648 May 3, 2012 every page. City/Town State Zip Code Date of Inspection B. Certification (cost.) • B) System Conditionally Passes (cont.): . a ❑ 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 tha 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with app oval 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 i 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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 940 Cotuit Road (Route 149) Property Address William Reilly Owner Owner's Name information rts r Marstons Mills MA 02648 May 3, 2012 every for page. Cityrrown 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 t e SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS a the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and th 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 an sis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and th presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no her 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 Y2 day flow t5ins-11/10 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 4 of 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 940 Cotuit Road (Route 149) Property Address William Reilly Owner Owner's Name information is y required for Marstons Mills MA 02648 May 3, 2012 every,page. Cityrrown 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 mus/bovethe either"yes or"no"to each of the following, in addition to the questions in Section D. Yes No E] ❑ the syithi 400 feet of a surface drinking water supply ❑ ❑ the syi in 200 feet of a tributary to a surface drinking water supply ❑ the sycated in a nitrogen sensitive area (Interim Wellhead Protection Area or a mapped Zone II of a public water supply well If you have answered "yes" uestion in Section E the system is considered a significant threat, or answered"yes" in Sectioe the large system has failed. The owner or operator of any large system considered a signifiat 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 5 ' b Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' 940 Cotuit Road (Route 149) Property Address William Reilly Owner Owner's Name information is Y Marstons Mills MA 02648 May 3 2012 required for + every page. Cityrrown 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): GPD ins'111110 rifle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 6 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 940 Cotuit Road (Route 149) Property Address William Reilly Owner Owner's Name information is Marstons Mills MA_ 02648 May 3, 2012 every page. City/Town State Zip Code Date of Inspection D. System Information Description: i. Number of current residents: 4 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes Z No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 2010= 173 GPD 2011= 186 GPD Detail: Recommend removal of garbage disposal unless new system is designed to handle Sump pump? ❑ Yes ® No Last date of occupancy: Current 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. tc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank pres nt? ❑ Yes ❑ No Non-sanitary waste discharge to the Title 5 system? ❑ Yes ❑ No Water meter readings, if av ilable: t5ins-11110 Title 5 Official Ins pection Forth:Subsurface Sewage Disposal System•Page 7 of Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments J� 940 Cotuit Road (Route 149) Property Address William Reilly Owner Owner's Name information is requi;-ed for Marstons Mills MA 02648 May 3 2012 eery page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Ready Rooter records: Pumped 06/05/2009 Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? Site tube on truck Reason for pumping: maintenance 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 940 Cotuit Road (Route 149) Property Address William Reilly Owner Owner's Name information is Marstons Mills MA 02648 May 3, 2012 required for y every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: System installed 1975. Age of home. Were sewage odors detected when arriving at the site? ❑ Yes ® No x Building Sewer(locate on site plan): 28'i Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 20"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: 8.5'X 4.5'X 4.5' 1000 gallons Sludge depth: 21 0 t5ins•11t10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 9 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y� 940 Cotuit Road (Route 149) Property Address William Reilly Owner Owner's Name information is y required for Marstons Mills MA 02648 May 3, 2012 every page. City/-rown state Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) 36" Distance from top of sludge to bottom of outlet tee or baffle 4" Scum thickness Distance from top of scum to top of outlet tee or baffle 6,1 Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? Tape measure and dip tube. Comments (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet concrete baffle and outlet PVC tee in place. Liquid level at outlet invert. Light staining 2"over outlet invert. Risers bring covers within 6"of grade. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: El 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 11110 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 940 Cotuit Road (Route 149) Property Address William Reilly Owner Owner's Name information is y required for Marstons Mills MA 02648 May 3, 2012 every 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 940 Cotuit Road (Route 149) Property Address William Reilly Owner Owner's Name information is Ma required for rstons Mills MA 02648 May 3, 2012 every 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 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 D-Box Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump cha er, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 12 Commonwealth of Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 940 Cotuit Road (Route 149) Property Address William Reilly Owner Owner's Name information is Marstons Mills MA 02648 May required for y 3, 2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cons.) Type: ® leaching pits number: 1-6'X 6'w/stone ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ Teaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Liquid level in leach pit over inlet invert. Leach pit is in failure. 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 I ❑ Yes ❑ No t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System foam -Not for Voluntary Assessments 940 Cotuit Road (Route 149) Property Address William Reilly Owner Owner's Name information for required Marstons Mills MA 02648 May 3, 2012 every 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.): a f5ins•11110 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 14 of 14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 940 Cotuit Road (Route 149) Property Address _Wiliam Reilly owner ow fmft NWM Q1 MMUM is Marstons Mills MA 02648 May 3,2012 every p w- CWrown state Zj code Date of Urn D. System Information (corn.) 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 p drawing attached separately i 7� ' A3- — �+ each _a3 T ` ` © 3 15h�•111t0 ( rift 5 oftw h"ftfi n Fom SLlae&M Sewage Disposal •Rage Isof 1s i k Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 940 Cotuit Road (Route 149) Property Address William Reilly Owner ' Owner's Name information is y required for Marstons Mills MA 02648 May 3, 2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) + Site Exam: El Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: '5 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 4 ❑ 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: ma.water.usgs.gov terraserver-usa.com You must describe how you established the high ground water elevation: Property elv= 90. Base of leach pit at elv= 81.Accessed local ground water contours and topo mapping. No high ground water in area of system. I 1. Before filing this;Inspection Report, please see Report Completeness Checklist on next page. t5ins-11/10 { Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 16 of 16 I I r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° 940 Cotuit Road (Route 149) Property Address William Reilly Owner Owner's Name information is y required for Marstons Mills MA 02648 May 3, 2012 every 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 1 t5ins•11110 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 17 TITLE 5 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION RECEIVE® Property Address:_940 Cotuit Rd.Marstons Mills Owner's Name: Ralph Mason S E P 0 3 2003 Owner's Address: same as above TOWN OF BARNSTABLE Date of Inspection:_8/25/03 HEALTH DEPT. Name of Inspector: (please print)_Eric Stevens 9AP ® ) Company Name: Mailing Address:_20 Oriole In.Marston Mills PARCEL ; ® a'� Telephone Number:_(508)776-9054 LOT 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 Fails 9 4i-Inspector's Signature: Date: 2ln The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) i Property Address:_940 Cotuit Rd.Marstons Mills Owner: Ralph Mason Date of Inspection:_8/25/03 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D Y 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 CNIR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order,and in sound condition.Passes title V inspection. 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 mill 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 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 PART A CERTIFICATION(continued) Property Address:_940 Cotuit Rd. Owner: Ralph Mason Date of Inspection:_8/25/03 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: OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_940 Cotuit Rd. Owner: Ralph Mason Date of Inspection:_8/25/03 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 'h 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 I 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 VO LUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:_940 Cotuit Rd. Owner: Ralph Mason Date of Inspection:_8/25/03 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? 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 Eased on: Yes no x _ 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(3)(b)] OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 940 Cotuit Rd. Owner: Ralph Mason Date of Inspection:_8125/03 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_3_ Number of bedrooms(actual):_2_ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):_330 Number of current residents:_I Does residence have a garbage grinder(yes or no): no_ Is laundry on a separate sewage system(yes or no):no_ [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no):_no_ Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no):_ Last date of occupancy:_present COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Lypd 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: owner's family Was system pumped as part of the inspection(yes or no):no_ If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _x_Septic tank,distriburion box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternativ.-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: System was installed in 8/75 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 PART C SYSTEM INFORMATION(continued) Property Address:_940 Cotuit Rd. Owner: Ralph Mason Date of Inspection:_8/25/03 BUILDING SEWER(locate on site plan) Depth below grade:_18" Materials of construction: _cast iron _x_40 PVC other(explain): Distance from private water supply well or suction line: town water Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_(locate on site plan) Depth below grade:_12" 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: 1,816"HS7"W4'10" Sludge depth:_4" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness:_6" 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: 12" How were dimensions determined: measured 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 working order,recommend pumping now and then every other year. GREASE TRAP:_(locate on site plan) Depth below grade: Material of construction:_concrete metal_fiberglass_polyethylene_other(explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_940 Cotuit Rd. Owner: Ralph Mason Date of Inspection:_8/25/03 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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is ievel and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): D-box was not located PUMP CHAMBER: (locate on site plan) Fumps in working order(Ves 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 PART C SYSTEM INFORMATION(continued) Property Address:_940 Cotuit Rd. Owner: Ralph Mason Date of Inspection:_8/25/03 SOIL ABSORPTION SYSTEM(SAS): x (locate on site plan,excavation not required) If SAS not located explain why: Type _x_leaching pits,number:_1_ 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.): 1 1000 gal.pit was in good shape and had 18"of water in it at time of Lnspection.No sign of staining at a higher level. 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: Lndication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.): OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_940 Cotuit Rd. Owner: Ralph Mason Date of Inspection:_8/25/03 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. �l V o� Crai�°1e. � t u� = 10112 AZ_ 3�1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_940 Cotuit Rd. Owner: Ralph Mason Date of Inspection:_8/25/03 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water_18 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) X Accessed USGS database-explain:_Internet You must describe how you established the high ground water elevation: USGS maps and charts I'�..�z { ? � 6 ,h � �. ��� r �. r COMMONWEALTH OF MASSACHUSETTS r z d EXECUJIVE OFFICE OF ENVIRONMENTAL AFFAIRS b j d DEPARTMENT OF ENVIRONMENTAL PROTECTION � eW RECEIVE® JR 1 .7 2001 TTawrl QF t3ARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—,NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: Zco 0rjo1e 1N Owner's Name: eve v� Owner's Address:26 Date of Inspection: 01 Name of Inspector: (please print) Company Name: Mailing Address: Telephone Number: 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 15.600). The system: Passes Conditionally Passes Ne F her E lu the Local ApprovinOardof Authorit a' c Inspector's Signature: Date: The system inspector shall submit a copy of this inspection report to the Approving A oriealth 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 �4o wo�,l:�r e Omer avA vlatsScS ****This report only describes conditions at the time of inspection and under the conditions of use at.that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:& \eo_ Owner• <Sbc- Date of Inspection: `1 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: V 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: \\ ��i. �� ��. wo �►' r � � a ih 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 indill'ating 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 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: Page 3 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A \CERTIFICATION(continued) Property Address: ZO 66a\e- lii. ' i��o•�� �(V�.��� Owner• & ' w. 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 the system is ailing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: - Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water.supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**.Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:2p Oc,CNe Owner: �fc; .,� Date of Inspection: `1 1— 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''/2_day flow �C 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. -�C 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 b 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. Pag:5 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: GM-C.'V 1w_ Owner: &i L Date of Inspection: J) 1 c» 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 7 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 —ma ",tan�1 W.-af-VM4%1arfarr w-up.ue -------- The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no _ 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) 1310 CMR 15.302(3)(b)j Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: ZC Cr,o\e `'1S- S Owner: 'Ex- CC- S Date of Inspection: 1 � FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): �. DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):•31Q) Number of current residents: 7�1 Does residence have a garbage grinder(yes or no):N® Is laundry on a separate sewage system(yes or no): [if yes separate inspection required] Laundry system inspected(yes or no):/VO Seasonal use: (yes or no):AZO Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no):&D Last date of occupancy: COMMERCIALANDUSTRIAL 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: Was system pumped as part of the inspection(yes or 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) Tight tank _Attach a copy of the DEP approval _Other(describe): ' Approximate age of all components,date installed(if known)and source of information: i4am-c:�1C. l.i ye Were sewage odors detected when arriving at the site(yes or no): Q Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Zb Owner: Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: aa,, ' � Materials of construction: _cast iron V 40 PVC other(explain): Distance from private water supply well or suction line:<. "\W, Comments(on condition of joints,venting,evidence of leakage,.etc.): SEPTIC TANK: (locate on site plan) Depth below grade: 17 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) DimensionsLY C1 N GY y l loin Sludge depth: 10 it Distance from top of sludge to bottom of outlet tee or baffle: a9 Scum thickness: q 11 Distance from top of scum to top of outlet tee or baffle: 7 Distance from bottom of scum to bottom of outlet tee or baffle: Its �► How were dimensions determined: l�(lezS� Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to o le t invert,evidence of leakage,etc.)):` \ suslE.M \S \t. g�� Wo��lhd 6Cae_-r GREASE TRAP:Alocate on site plan) Depth below grade: _ Material of construction:_concrete_metal fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to,top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping-recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ZO ar. Owner: ic- Date of Inspection: `7 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/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:NI (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any.evidence of leakage into or out of box,etc.): PUMP CHAMBER: V (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Z le Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: T Bleaching pits, number: LOOo 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.): n 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: (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.): Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner:•F L 5 Date of Inspection: -115 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. 1'E:c yA�� k Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSr1RFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 20 At `del. ,1�nn arAclv�� ��\\S Owner: Date of Inspection: SITE EXAM Slope - - Surface water Check cellar Shallow wells Estimated depth to groundwater feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you establishe the high ground water elevation; 6w �S pe-rc- 7 RECEIVEt .._:�._. r JUL 1 7 2001 TOWN OF BARNS 1"AlsLt � HEALTf1,nEPT' v.._ F COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Graci DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE ® � ® Secretary ARGEO PAUL CELLUCCI STRUHS Go mi�i�on ae Governor _ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION �ORNI � pq1 PART A CERTIFICATION Property Address: 20 ORIOLE RD. MARSTONS MILLS 'n ro < Name of Owner RICHARD BRUNNING p �", Address of Owner: 23 JAMES OTIS RD.CENTERVILLE MA.02632 �co y �`99 Date of Inspection: 4/13/99 Name of Inspector:(Please Print)JOHN GRACI 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: DEP TITLE V INSPECTIONS Mailing Address: BOX 2119 TEATICKET MA.02535 Telephone Number: 608-564-6813 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems..The system: X Passes The inpection is based on criteria defined in Title V _ Conditionally Passes code 310 CMR 15.303.My findings are of how the system Is _ Needs Further Evaluation By the Local Approving Authority performing at the time of the inspection.My inspection does Fails not imply any warranty or guarantee of the longgevity of the septic system and any of its components useful life. Inspector's Signature: Date:4/18/99 The System Inspector shal ubmit 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 THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING THE TANK NOW AND THEN MAINTAINED EVERY TWO YEARS. revised 9/2/98 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 20 ORIOLE RD.MARSTONS MILLS Owner: RICHARD BRUNNING Date of Inspection:4/13/99 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: nta One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. Wit 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. n& Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced _ obstruction is removed distribution box is levelled or replaced n& The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): _ broken pipe(s)are replaced obstruction is removed revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 20 ORIOLE RD.MARSTONS MILLS Owner: RICHARD BRUNNING Date of Ins pection:4/13/99 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance nla_(approximation not valid). 3) OTHER Wa revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 20 ORIOLE RD.MARSTONS MILLS Owner: RICHARD BRUNNING Date of Inspection:4/13/99 Check if the following have been done:You must Indicate either"Yes"or"No"as to each of the following: Yes -No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [1 5.302(3)(b)] X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2198 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART C SYSTEM INFORMATION Property Address: 20 ORIOLE RD.MARSTONS MILLS Owner: RICHARD BRUNNING Date of Inspection:4/13/99 FLOW CONDITIONS RESIDENTIAL: Design flow:—M g.p.d./bedroom Number of bedrooms(design): 2 Number of bedrooms(actual):2 Total DESIGN flow: 2ZQ Number of current residents:A Garbage grinder(yes or no):NQ Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no):-W Seasonal use(yes or no):JLQ Water meter readings,if available(last two year's usage(gpd): nLa Sump Pump(yes or no): NQ Last date of occupancy: Wa COMMERCIAL/INDUSTRIAL Type of establishment: n& Design flow: n&gpd(Based on 15.203) Basis of design flow: n& Grease trap present:(yes or no):JW Industrial Waste Holding Tank present:(yes or no): NO Non-sanitary waste discharged to the Title 5 system:(yes or no):No Water meter readings.if available:n& Last date of occupancy: n& OTHER: (Describe) nLa Last date of occupancy: n& GENERAL INFORMATION PUMPING RECORDS and source of information: nLa System pumped as part of inspection:(yes or no):NO If yes,volume pumped nla- gallons Reason for pumping: n/a TYPE OF SYSTEM X Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes.attach previous inspection records,if any) I/A Te,--hnology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: n& APPROXIMATE AGE of all components,date Installed(if known)and source of information: SYSTEM IS APPROXIMATELY 10-16 YEARS OLD. Sewage odors detected when arriving at the site:(yes or no) NO revised 9/2198 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 20 ORIOLE RD.MARSTONS MILLS Owner: RICHARD BRUNNING Date of Inspection:4/13/99 BUILDING SEWER: (Locate on site plan) Depth below grade: 22" Material of construction:_ cast iron _40 PVC X other(explain) Distance from private water supply well or suction line: TOWN Diameter: nla Comments: (condition of joints,venting,evidence of leakage,etc.) n1a SEPTIC TANK: X (locate on site plan) Depth below grade: HE Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) nta If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): XG Wa Dimensions: L 6'6"H 5'7"W 4'10" Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle: ZE Scum thickness: 6" 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: ]2" How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING SYSTEM NOW AND THEN MAINTAINED EVERY TWO YEARS GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) nLa Dimensions: n(a Scum thickness: nla 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 n& Date of last pumping: Wa Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) nla revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 20 ORIOLE RD.MARSTONS MILLS Owner: RICHARD BRUNNING Date of Inspection:4/13199 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: nLa Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) nLa Dimensions: n& Capacity: n& gallons Design flow: n/a gallons/day Alarm present: MQ Alarm level:jiL& Alarm in working order:Yes—No—: NO Date of previous pumping: n& Comments: (condition of inlet tee,condition of alarm and float switches,etc.) n/a DISTRIBUTION BOX: _ (locate on site plan) Depth of liquid level above outlet invert:n& Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) to PUMP CHAMBER: NQ (locate on site plan) Pumps in working order:(Yes or No): NQ Alarms in working order(Yes or No): NQ Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 20 ORIOLE RD.MARSTONS MILLS Owner: RICHARD BRUNNING Date'of Inspection:4/13/99 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: Type: leaching pHs,number: 1000 GALLON LEACH PIT leaching chambers,number: -nLa leaching galleries,number: j3& leaching trenches,number,length: n& leaching fields,number,dimensions: nLa overflow cesspool,number: n& Alternative system: n& Name of Technology: jVa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY PIT WAS EMPTY AT THE TIME OF THE INSPECTION NEVER MORE THAN T OF CESSPOOLS: _ (locate on site plan) Number and configuration: n& Depth-top of liquid to inlet invert: n& Depth of solids layer: n& Depth of scum layer. n& Dimensions of cesspool: nLa Materials of construction: nLa Indication of groundwater: n& inflow(cesspool must be pumped as part of inspection)n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nla PRIVY: _ (locate on site plan) Materials of construction:n& Dimensions:n& Depth of solids: n(a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n& revised 9/2/98 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 20 ORIOLE RD.MARSTONS MILLS Owner: RICHARD BRUNNING Date of Inspection:4/13/99 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a Deck o1A �4 fig. �A ay ag y 1 revised 9/2/98 Page 10 of 11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 20 ORIOLE RD.MARSTONS MILLS Owner: RICHARD BRUNNING Date of Inspection:4/13/99 NRCS Report name: n& Soil Type: n& Typical depth to groundwater: n1a USGS Date website visited: n& Observation Wells checked: NQ Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated'Depth to Groundwater 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record X Observed Site(Abutting property,observation hole,basement sump etc.) _ Determined from local conditions _ Checked with local Board of health Checked FEMA Maps _ Checked pumping records _ Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation. Must be completed) Y 9 ( P 1 USGS MAPS AND CHARTS AND VISUAL revised 9/2/98 Page 11 of 11 r f�. Fxs... ........... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ...---_....-- .Town..........oF........B.arns.tabl.e------------------------------------------------•- Appliraation for Elispniital i9orkii Tnntiirnr#iun, rrnti# Application is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal System at: ZO t 7T. I.�. o --------------- Location-Address or Lot No. .......... Realty..Trust 6 a a Owner Address Installer Address Type of Building Size Lot...........................Sq. feet U Dwelling—No. of Bedrooms--_------.3-------------------------------Expansion Attic ( ) Garbage Grinder ( ) pa, Other—Type of Building ranch............... No. of persons............................ Showers ( 2) — Cafeteria ( ) G" Other fixtures ..------•--••-•--•---•-•--•..... . . - W Design Flow.............5.5......................... per person per day. Total daily flow.................._ 3.Q.................gallons. WSeptic Tank—Liquid*ca.pacityl_Q-Q.Q_.gallons Length 8._.6....... Width..4.'1_0". Diameter________________ Depth. '.8...... x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area............_..._...sq. ft. 3 �.__..... Depth below inlet......6.......... Total leaching area....?_66.....sq. ft. Seepage Pit No..................... Diameter.___.__6 Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed b ..... 1.1dre. e...En.i2ae.ex'in Date..... 1--2 -8�............._ ,.� Test Pit No. l�2.0__ minutes per inch Depth of Test Pit___-12.!........ Depth to ground waternone_--encounter�- Test Pit No. 2.N1�..._..minutes per inch Depth of Test Pit....N�A....... Depth to ground water___...VA....._... e a ........................................................------------------ ........ -----•--•......--........................................................ O Description of Soil------.Q._....-....2............loam._&...to. S.o i 1............................................................................................. 2 ' -..10 ........ edium..-yellow---Sand------------------- - -- ----------------..............-•-•--. W 10 ' - 12 ' med..•.white- sand/trace.s....of.• -ravel•/no-_-water at•_.12 ' 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 T TILE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Com liance has been is led by the board of health. Sig -----------•--- .............................. � 5...e Application Approved By-•- = ----- ------------------------------------------------------------------------ �2.. :-yY Date Application Disapprov f h following reasons:..............................................--................................................................ ......................... •..... ......•••-••---------••--•-••...•--••------------........--•--•--•-•----•----•-•--•-••----•-•-••............................. ............................. Date Permito------ ................................................ Issued-..................................................... Date No:.......Z� 2j f FEB...3r"............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -----------------Tom..........OF.......Barnsta-bi:e------------.......-.---_.--.-----------_--..._---- Appliration for Disposal Norks Tongtrnrtiun rrmit Application is hereby made for a Permit to Construct -(X) or Repair ( ) an Individual Sewage Disposal System at: ............. .._ ..� ..... _!. (�1So.r_...e C1.. ............ ................... .... Location-Address or Lot No. • -Cap 'z Q 'xa...k� alty.--Trust------------------------- -?-65---F'a.1=-Uth �R�ad,•- ;ya. 3�--.................. owner Address ............................................................ ..........................--•--...---.........--------•--..........------••---•--••--•-------•---• Installer Address dType of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms........... ................. .. .Expansion Attic ( ) Garbage Grinder ( ) per, Other—Type of Building2Zanah............... No. of persons............................ Showers (2 ) — Cafeteria ( ) a Other fixtures ...................................................... W Design Flow............. ..........................gallons per person per day. Total daily flow...................3LO..................gallons. WSeptic Tank—Liquid*capacit�0.00..gallons Length8.'_6....... Width.4 1Q'.... Diameter................ Depth!.$!!..... x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..........1_______-. Diameter.._....6_�..._..... Depth below inlet.....b..'_......... Total leaching area_..2b6......sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '-' Percolation Test Results Performed by....Eldradge..E11ginee�'.],ng........... Date....11-25-8-1-----_------ Test Pit No. 1 21/.�.. minutes per inch Depth of Test Pit... 2.!......... Depth to ground watelt7QYnB...e11Counte fi Test Pit No. 2Pl.....__minutes per inch Depth of Test Pit---F/A........ Depth to ground water.....�j/A.......... P4 .......... -------I-------•----------••-•-•----------•--...--•••-•-•--•.....-----•............................•-....................----._..................---•--... p - S s • Description of Soil-----d-�-••'---�--.�....--�-O�.v1.-&--•t4Sa-�-----------------------•------•----------•----------------••---•----••----...._......------•--- x 2-- -- 1�_..----meth una---vo low--zand...........................:...................................................... W -----------•-------- ... �2-..-----med....white...Sa? _V.tra.._e_eZ---af--- Mmal/--no...Vlater.-at--12• 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 TITTLE 5 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. ir { Sig .............................. ' ��...... Application Approved BY * t .8 f' Sri Date Application Disapprove f o following reasons-----------------------------------------------------------------------•----. .....------. •--------•--....._ f/ he . 1 Date Perm><t No. -•................••--••••--•------•--------. Issued......---••--------------------------•----------•--•--. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...............Tovm.............OF....Earnatable................................................ Trrtifiratr of ( ompliFanrr by THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed YE ) or Repaired ( ) ....••..-----•--•-....b..•e- ----.....•-.el.... .1t- 1y--------------------------------------------------------------------------------------- --•...•.. -- 1r Installer �/ ) , a � � G z /o at.I'.Ot-----•-• fr '1.L_�st... 1 ................................ has been installed in accordance with the provisions of TIC' F' 5 o The State Sanitary Code/as. ed in the application for Disposal Works Construction Permit No............... .....................f.............. dated__. :S............................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SAT SF CTORY. DATE......................................... .. ..6 �•----•---•---• Inspector..................... � ......................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �ovm OF Barnstable �aC �Ct V .......................................... .... .............................................._............ FEE..�� ............ N o......................... Disposal Works Trainotrnrtuan rrmit Permission is hereby granted-----------------=Y-- .............A. to Co str ct (X ) or Repair ( ) an Individual Sewage Disposal S stem atNo...---•---- �... - 2�-..,,..�. ...................................... �" Street­' treet ZsC.r�rf !/ L ..0�... ..... as shown on the application for Disposal Works Construction Permit No___ _____________ Dated.......................................... .................................................... -..; . .... •. ..................... Boar Health DATE..........G -3" -----••-------•--••---•----•----•-- FORM 1255 HOBBS & WARREN, INC., PUBLISHERS Ii 5 S 144 opr 01 1- r � ` �EZ-: 2�: g iN 2M4 i? o �' F iT 5F-T 13A, hV SUR��' es- ��Qk �iE A�J.�I.n i=G P�ec^51��-; yr_-�t•.i .�s*.,:G�� �'T'. LEGEND ,, -M: ctiAPT isr, G-E EEISTINS SPOT ELEVATION CAA �� FMB. CERTIFIED PLOT PLAN EXIETIN® CONTOUR --- O ___ ��P a��� t_ �,��.1� FINISHED , SPOT ELEVATION ALB PINIONED CONTOUR - 0---- A: \ ��" MAP::E`r�N M I;� S (OR� , A 0VED= 9OARD of HEALTH nNo.10951LO�� IN SAAAS"tASL9 MA"* ONAL BATE ASENT ^� SCALE I"= 40 DATE 05 e'L EORE ENB/NEER/NQ CQ / CLIENT i CERTIFY THAT THE PROPOSED ®1� E REBISTEME JOB NO. BllILDINO SHOWN ON THIS PLAN :CIVIL , LAND CONRORIIlB TO THE ZONING LAWS V Oil.BY OF BARNSTAB E, ABS. Exec' 712 MAl N STREET, CH. BY, AAM s MYAwNl3,. MA33. i 2 loe2 C _.,� SHEET Of _._. DATE itLAND SURVEYOR r. 1 20 FT. M/N. /1(07E /F E/TNER TsaE SEPT/G 7-A V.I< OR ' G.EAGH/NG P/T ARE MORE TH.9:'/ /Z"BELOJV /O. fT. M/N. J.RAOE� A 24 'O/AM ETER C'ONC'R ETA �Ot�ER CONCRETE N AYy�AST�RON coV�R SH4LL /(3E USEO P"PVC P/P� — EL= i0O.S COVERS - M/N. PITCH /F/N DR/VElti.4 y `a''• �B oEiQ FT A GR•4oE cv rER CLEAN .SAND LQl//D LEVEL t. 4. 4"CA$7, - - "LAYER /RQ/V R/PE e • o qF 'd MlN.PJ TGII 1 00� GAL. • I • • • • . • r r oP•4 :VV Foil JET. SEPTIC TAAIX D>sT, • b • • • • • • • r r • e a IYASHFD STrJNE . BQX 0 • • B • • • see ,►0 •, .� e � •s � r • •EFFEcr/VC r • . •� 3�a - l �2 • n r • • pEPTt/ • • • ' ' o . WA5.,YED STO YE . '-;.i � - - n ••fie I • -• • • • • • r - pp o 180.5 X 2.S.= 4 11 G/D • n. pop • • • • • e • r p PRECAST SEEPAGE a �e r • • • . • o • r ' e o P/TOR EQU/V. /Nk'4wXr ELEVATIONS -70.5 x ko -78 G( D a $ — EL 5 INVERT AT OU/LD/NG 9-7.5 FT INLET. WPr/C TANK q1. 3 FT, PIT CAPAGrt� : 549 GAD � l0 FT 0/AM. C SEET,-WUL.ATJOt) aaTLET SEPTIC TAN. H 97 •1 FT. INLET 4o/S7R/8!/T/ON BOX q G •9 & GROUND W,4TER TABLE SECT/ON OF Ot/TLETD/.STR/BLl7YON BOX 9 , FT SFI�VAGE O/.SPQSA L SYSTEM INLET LgACN/NG 4c;'/7 9 •`.�.FT, L EACH//VG fs/T TABULATION SCALE %4 _ /= D' DIMENS/ON A DES/GN CRITERIA D/.�fr=xs/O N 8�-FT. i NUMBER OF BEDROOMS 3 ®/HENS/ON C 4 FT. M i N GAR9A-GE D/SPO,S.4L (/NIT NONE SO/L LOG G r TOTAL E.?T/MAfTED =LON/ 33� GAL.�DAY SO/L. TEST / $OIL 7;G 7**2 •���L TEST NUMBER aF LEACN/NG PITS_ I �FLEK �5.5ELEY, L S/DE LEACH/NG PER.P_./T I BB OATS OF SOIL 7-EST B OTTOM LEA CH/NG P/T 78 PER L�� RESULTS h//TNESSED BY J���1 =D �' FT 1c'4`4VC044A7-/0N RATES AEI TOTAL LEACHING AREA 2� SQ, FT. 700�'oti-- PENCO.AT/ON RA7E,*2 14A MIN.1/NCH RESERVE44S4CN//VGAREA.2CaCc SQ, F,T. AAA OF Mgs`S9 �P�tN asses I.2 I/L LOT I l — CP-t dL1= LAN C o A B T 9G SF�tSp E Lp, , fU/��IONS.MILLS- aPrP-�iAa'LC g y 'ORSE �, e No.10951 O ' �� _ �o ����� A9 �F��sTE ��`� L EL DREDGE ENGINEERING CO,/NC. ..n` NI R�y0 �FSS/ONAk- " EL- �.5 7J2 MAIN ST. , AlYANNiS.'su ® NOGROU/VO pv,47*4 EvC'OUNTEREO CL/EMT:�E ; I DRTE (to /a'L Q GRO UNO h/ATER JOB No. 8205o SHEET?- OF �- c, TOWN OF BARNSTABLE '" LOCATION DC y� l L �CO� SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) L�� (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) /! / Feet Furnished by hh t ( �d b It 1 � O e �b1c�- TOWN OF BQ ARNSTABLE 'pl� wo LOCATION a SEWAGE # VILLAGE s 1 ASSESSOR'S MAP &LOT IT— INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY / 00 'L LEACHING FACILITY: (type) ��SJ Q7�_ (size) 1�� NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: COMPLIANCE_DATE: Separation Distance Between the: . Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 2� �7' IA a A AA y 55 Ac FAaw t3� 99 l CATION rto � py SEWAGE PERMITp0• . %/ef , VILLAGE Ufa - 0�9 I N S T A LLER'S DAME A ADDRESS y, c 6 U I L D E R- OR OWNER Ey ah. CQ DATE PERMIT IS-SUED DAT E COMPLtA-NCE ISSUED /G��� r t a P Ay S,z 0