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HomeMy WebLinkAbout0254 REGENCY DRIVE - Health 254 REGENCY DRIVE, MARSTON MILLS 060 i i COMMONWEALTH OF MASSACHUSETTS u EXECUTIVE..OFFICE OF ENVIRONMENTAL AFFAIRS i DEPARTMENT OF ENVIRONMENTAL PROTECTION � . ' V RECEIVED v` JUL 19 2001 TOWN OF BARNSTABLE HEALTH DEPT. ITITLE 5 OFFICIAL INSPECTION.FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE'SEWAGE DISPOSAL.SYSTEM FORM PART A CERTIFICATION Property Address:. J 0. Owner's Name: � ya2l�w Owner's Address. Date of Inspection: Name of Inspec or: please rint)��,e �-• 1 L�Yi P '�1 Company Nama Mailing Address: .O- �zq o 0(PVC 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 purl suant/Passes toSection 15.340 of Title 5(310 CMR 15.000). The system: Conditionally Passes ds.F rther Evaluation by the Local Approving Authority ails r' Inspector's Signature: Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health.or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office ofthe 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. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of I l OFFICIAL INSPECTION FORM—NC IT FOR VOLUNTARY.ASSESSMENTS - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM CERTIFICA ION(continued) Property Address: W !Ij 1. Owner• ��"� ..., . Date of Inspection: .c3/ Inspection Summary: Check A,B,C,D or E/ALWA S complete all of Section D A. w System Passes: J I have not found any-information which.indicates: hat any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria.n t;evaluated are indicated below. Comments: B. System Conditionally Passes: One or mores stern components as described in the"Conditional " y p onal Pass section need to be replaced or repaired.-The system,upon completion of the replacemen.or repair, as approved by he"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 infiltrati6n or exfiltration or.tank failure is imminent. System will pass inspection if the existing tank.is replaced with a complying septic tank as' pproved'by the Board of.H.ealth. *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 availab e. ND explain: Observation of sewage backup or break out or high static wa ter 1level 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 re flaced obstruction is`remov ed distributianbox is le eled or-replaced ND explain: The system.re4uired 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: i Page 3 of 1'1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued). Property Address: Owner: Date of spection:. 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)(P..)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: 3. Page 4 of I I OFFICIAL:INSPECTION FORM NOT FOR VOLUNTARY'ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION;FORM PART A CERTIFICATION(continued) Property Address: P + Owner: Date of lns ection: 01/67 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the.following for all-inspections: Yes N/ _ Backup of sewage into facilityor system component due to overloaded'or,clogged SAS or cesspool Discharge or pond.ing 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 I Liquid depth in cesspool is less than 6"below invert or available volume is less than %2 day flow �/ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number _ 7of 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 l 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 coliform bacteria and volatile organic compounds indicates that the well is free-from pollution from that facility and the.presence of ammonia nitrogen-and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered:A copy of the analysis must be attached to this form:) (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 C.MR 15.303,therefore the system fails. The system owner should contachthe 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"desigu flow of 10,000 gpd 615,000 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 i.s.within 400 feet of a surface drinking water supply _ the system is within NO 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 weft If you have answered"yes"to any questibn 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. 4 Page 5 of 1.1 OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS -SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION"FORM PART B CHECKLIST Property Address: a Own— Date of Inspection: —7/&Zo / 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.ofwater been introduced to the system recently or as part of this inspection? A_ Were as built plans of the system obtained and examined?(If they were not available note as N/A) V _ Was the facility or dwelling inspected for.signs of sewage backup? 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.de.termined 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)[310 CMR 15.302(3)(b)] 5 Page.6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARYASSESSMENTS SUI;SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C _ SYSTEM INFORMATION Property Address: Owner.- Date of Inspection: '7 p J FLOW CONDITIONS RESIDENTIAL V Number of bedrooms(design): .2 Number of.bedrooms(actual):. DESIGN flow based on 310 CviR 15.203(for example: 110 gpd x#of bedrooms): ,- .,Number of current residents.: `7 Does residence'have a garbage grinder.(yes or no)u� . Is laundry on a separate sewage system (yes or'no) if yes separate inspection required] Laundry system inspected(yes or no Seasonal use:(yes or no) �.. . Water meter readings, if avai]able(]ast..2 years usage(gpd)): . Sump pump(yes or no): (,1` a Last date of occupanc COMMERCIAL/INDUSTRIAL_/)t6- 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-nspecti n(yes or If yes,volume pumped: gallons--How was quantity pumped determined? Reason'for pumping: TYPrep F SYSTEM ic 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): pproximate age of all eo pone ts, date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM;INFORMATION(continued) Property Address: 695- � � Owner: ` �,PL�7v Date of Mspection: ") // A) / BUILDING SEWER(locate on site plan"'Zo Depth below grade: Materials of construction: ` cast iron._40 PVC_other(explain):- - Distance from private water supply well or suction line: Comments(on condition of joints, venting,evidence of leakage,etc.): SEPTIC TANK: Zoocate on site plan) a� Depth below grade: Material of construction: concrete_metal_fiberglass polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a.copy of certificate). Dimensions: ?"S7 Sludge depth: y Distance from top of sludge to bottom of outlet tee or baffle: 32- Scum thickness: �l Distance from top of scum to top of outlet tee or baffle:_2-_ Distance from bottom of scum to bottom of outlet tee or baffle: 3 How were dimensions determined: caowzha - Comments(on pumping recommendations, fnlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage, c.): 0 1 dd 10 let d�GeGSGp ���':�a� �,���e-�,n, �: . (,�?,Q.�.�lie i� ',��a�.�. .��✓''�� GREASE TRAP?22&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.): 7 Page &of I l OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY,ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM :PART C SYSTEM`INFORMATION(continued) Property Address: &Z O2P1! 1 Owner1* /�1s Date of Inspection: '7/zi ze) TIGHT or HOLDING TANI��' —(tank must be pumped at time of inspection)(]ocate on site plan) Depth below grade: Material of construction:. concrete ' metal - fiberglass Uolyethylene 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 fast pumping: Comments(condition of alarm and float.switches, etc.): f present must be opened)(locate on site plan) DISTRIBUTION BOX:Zi Depth of liquid level above outlet invert: al:'X� '� 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 CHAMBERr1&-7(locate on site plan) Pumps in working ✓✓order �r(yes or no): Alarms in working order(yes or no):. Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.): 8 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: + / ,-i) Owner: 146qmlea ' Date of Inspection:_T, SOIL ABSORPTION SYSTEM (SAS):. (locate on site plan,excavation not required) If SAS not located explain why: Type —Zleaching.pits,number: 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, n iialp/ j a 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✓.�A cate 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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-IS OT FOR VOLUNTARY ASSESSMENTS SUBSURFACE'SEWAGE DISK SAL SYSTEM INSPECTION FORM P `RT C SYSTEM INFOI . ATION(continued) Property Address: WV ca� 2w Owner: Date of Inspection: A)/. SKETCH OF•SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system includir g ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.Locate w ierepublic water supply enters the building. a � 31 � ` o 10 I Page I 1 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Property Address:-7 02 Owner: Date of Inspection:_�Ji�JU i SITE EXAM Slope Surface water Check cellar. Shallow wells Estimated depth to,ground water 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 established the high ground water elevation: 11 LSEP131996 IVED TROY WILLIAMS SEPTIC INSPECTIONS H DEPT. Certified by MA Department of Environmental Protection (506) 760-1819 40 Old Bass River Road South Dennis,MA 02660 Commonweaith of Massachusetts Executive Office of Environmental Affairs COPY Department of Environmental Protection VMlam F.Weld Trudy Cote cor.mar A W Paul Celluccl s.cwr.ry u.Gw.mor David B.Struhs SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A L CERTIFICATION Property Address: Q S'/ Iq'`f t h C-t 1 �✓. �°r S�eN f/"'���5 Address of Owner. /`)r f-Al, A/�s�� L Date of Inspection: g ,�l-�G / (If different) Name of Inspector. �vyy �,a/ c—vh y Sa rh Company Name,Address ar(d 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 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: Vse Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signal --S--"— '�j"��tya� Date e �� G The System Inspector shall submit a copy/of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A B,C,or D: A] SYSTEM PASSES: V/ I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: ^/111 One or more system componenu need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If"not determined",explain why not) The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or exfiltration,.or tank fadure is imminent. The system will pass inspection if the existing septic tank is replaced with a yonforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Addre" 2 s /�`y G On 1-/ Owner. (�Gam,K L Date of Inspection: u /3 d /'r(� BI SYSTEM CONDITIONALLY P!ASSES (continued) A111-9 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 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 CI 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 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 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. 3) OTHER i I (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: p?xq �Ly h Ly Owner. / Date of Inspection: LGv'`1 /30/Y6 DI SYSTEM FAILS: AIM I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. — Backup of sewage into facility or system component due to an 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 IN day flow. — sluiced 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. El LARGE SYSTEM FAILS: 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: — the system is within 400 feet of a surface drinking water supply — the system is within 200 feet of a tributary to a surface drinking water supply — the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area(IWPA)or a mapped Zone 11 of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CUR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: a S y /?z Owner. LG� rn L Date of Inspection: Check if the following have been done: ,/Pumping information was requested of the owner, occupant, and Board of Health. V 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. VA,built plans have been obtained and examined. Note if they are not available with N/A. ,/The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow /The site was inspected for signs of breakout. All system components,excluding the Soil Absorption System, have been located on the site. ✓The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction,dimensions, depth of liquid,depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. The facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: o2S y �G/ c h c Owner. Date of Inspection: RESIDENTIAL- FLOW CONDITIONS Design flow: :3 gallons Number of bedrooms: 5 Number of current residents: 02 Garbage grinder(yes or no):-�E 5 Laundry connected to system(yes or no):v J S Seasonal use(yes or no): NO Water meter readings, if available:_ Last date of occupancy: y c�-✓�o L� COMMERCIAL/INDUSTRIAIL NX� Type of establishment: Design flow:_gallona/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yea 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: L S �" pJ�p. D i �99L/ Lr iHJy U � ht� Cry 'l�v4t 6G./hLlr . System pumped ai part of inspection. (ryes or no) If yes, volume pumped: gallons Reason for pumping: TYPE QF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yea or no) (if yes, attach previous inspection records, if any) Other(explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: e.-r4� I I e 0//1/111-p �0.S - b,,: 14. Sewage odors detected when arriving at the site: (yes or no) IZl/6 (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C U SYSTEM INFORMATION(continued) Property Address: 0 5 / Ru L� y Owner. Date of Inspection: V /9 I SEPTIC TANK (locate on site plan) Depth below grader Material of construction: ✓concrete_metal_FRP—other(explain) - Dimensions: S x 9 "X /o 0 o y 4 /,o-I Sludge depth: :3" Distance from top of sludge to bottom of outlet tee or baffle:O? S Scum thickness: N--e- / Distance from top of scum to top of outlet tee or baffle: b Distance from bottom of scum to bottom of outlet tee or baffle: �y Comments: (recommendation for pumping, condition of inlet and et tees or baffles, depth of liquid level in rely to outlet invert,structural integrity, evidence f leakage,etc.) ��� s w c.��- aJ-. c, y d h , b.g o rd Q r A/v GREASE TRAP: /g (locate on site plan) Depth below grade: Material of construction: _concrete_metal_FRP—other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baIDes, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 11/03/95) g SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: p? L/ le`/ G h Owner. 7 Date of Inspection: �13D TIGHT OR HOLDING TANK��� (locate on site plan) Depth below grade: Material of construction:_concrete_metal_FRP—other(explain) Dimensions: Capacity:_ ¢allons Design flow: gailons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: <� Comments: /—� (note ' level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box,etc.) 1/'g-)G 4j c&V, PUMP CHAMBER: ^1 49 (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances,etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Address: a? Owner. L Date of Inspeotion: g SOIL ABSORPTION SYSTEM (SAS): V11, (locate On Site ple4 if possible;excavation not required, but may be approximated by non.intrusive methods) If not determined to be present,explain: Type: / leaching pits, number 0&A e b '� 6 ' L e-a —4 �;� Gv e� a leeching chambers, number:_ leaching galleries, number: leaching trenches, nuinber,length: leaching fields, number,dimensions: overflow cesspool, number:Comm eats: (note condition of soil signs of hydraulic failure, level of ponding, condition of vegetation,et�.) S., J��( CESSPOOLS:A1119 (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer. Depth of scum layer. Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (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 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: p?s `y Owner. Date of Inspection: J n e-- �/3 SKETCH OF SEWAGE DISPOSAL SYSTEM: Indude ties to at least two permanent references landmarks or benchmarks locate all wells within 100' 131 h t 3�' d26 �000q.l �a�w 1 DEPTH TO GROUNDWATER � Depth to groundwater. — feet adjusted high groundwater level method of determination or approximation: -�n /,�w-)- ,�vl o 4: ✓i ✓ 0. Ato�.e✓ 4- 6t Q d 4-c- eA ti A, c `r G va.��.R c✓�-E-e.� /w 9 TOWN OF BARNSTABLE L/ �w �LOCA'fION �S /'S c 9 �, L,c p SEWAGE # o 9—Z VILkY LGE S . ASSESSOR'S MAP& LOT INSTALLER'S-NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) /" �`T (size) 02 ,S NO.OF BEDROOMS BUILDER OR OWNER L-e— PERMITDATE: I/6 �5 L COMPLIANCE DATE: Z Z//Y/ Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leacl}in ,facility) Feet Furnished by W°t�' V L r f 4 rr i TOWN OF BARNS ABLE; VILLAGE at�S i.:.' � ASSESSOR'S MAP 8 LOT INSTALLER°S k&ME r PHONE NO- SEPTIC TANK CAPACITY�(� LEACHING FACIq.ITY:(t� ) i?r ��" (size) jM.2 NO. OF BEDROOMS `�� RIVA'IE +1EL OP. PIJBL'iC WATER BUILDER OR OWNER _ �Ncr � z ICLIA/ co DATE PERMIT ISSUED: DATE COUPLIANCE ISSUED:. i � VARIANCE'-G RANTED: Yes. 'No r �'�' r,` L.d� � � e. �� �I 4� D �, .�, `. �. � �� . �, � � � " _ � �� � . r �� tl� 0 No......................._ FEB ..........._....._ THE COMMONWEALTH OF MASSACHUSETTS -� BOARD OF HEALT lD[ .....o F...... 7 ��.......... ----------------•-- Appliratinn for Dhipaaal Workii Tonstrudinn 11amit Application is hereby 6rtowmade for a Permit to Construct ( xi or Repair ( ) an Individual Sewage Disposal System at: � � �� ................_......__.....•---............... ......... ....................-•---. -•---.........._._....._..........--••-----•••---•--•.._........._........------•--............. Locati0 - 'e or Lot No. ................ _... _ rZ; .... -E.... � _.. .........................(_2 ..4?..._...................._....... w Owner n I �n d ess ,a .. ...............v� _...... .:...........•.......................... ......................./G I C ... - •---Q:.--.... Installer Address �� Type of Building Size Lot...................._�S feet �.. Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria p" Other fix u es ................................... Design Flow........ /.- •- �-gallons per persclrr%�y. Total daily flow.......... ...............................gallo s¢ Septic Tank—Liquid*capacity`_..__.._._gallons Length................ Width: 1.0.... Diameter................ Depth .1-..... W Disposal Trench—No..................... Width.................... Total Length.................. Total leaching area....................sq. ft. x 3 Seepage Pit No........_._l_...._. Diameter......1L) i...._ Depth below nlet........0......... Total leaching area-'U.77, :0..sq. ft. Z Other Distribution box V) Dosing �(,,� �. a Percolation Test Results Performed b ... . .!�.�. - .�.,�. ..�.. Date..... .. ...................... Y t�.......•....... Test Pit No. 1...4-2. -.minutes per inch Depth of Test Pit....... ... ....,,Depth to ground ter..._... .___ .. .� Gt, Test Pit No. 2..��.minutes per inch Depth of Test Pit........ ._?v.. Depth to ground water.. a ............. . .... ............. `O De tion of Soil..- -...--D•-'.�Z .. �. .=L s . . � L x ••--.............. ..... .... - -------------------------------------------------------------- ....---------------..........-----..........----•...............-----------.... 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.:ITLZZ 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i ued by the board of health. Signed. r ... ........ .............All---------------------------------- �j l� '......... Date ApplicationApproved By..... ..................:. ... .. ... ..................... ............ ........................................ Date Application Disapproved for the following asons:.................................................................•---•-•----.........._....._................_ •&JI .................................. -�--•-•- --- •---•.....•---•-••••-••----..........-•--••---.....-•-•-.....••-•-.................--------•----------•-•--- -Date` .......... PermitNo.. ...........• -------------------.. Issued......._......_........._..-•--•----._.......... Date s Department of Environmental Management/Division of Water Resources �= i i WATER WELL COMPLETION REPORT _ ,sELL LOCATION Address Ao/ L1? �1 e C�/ 0/n. (A. 2 �0 Sro M City/Town/tl0� ",S^4�//& a. /✓a G.S.Quadrangle Map Grid Location Owner its v47 tl a 16 AI Ui—r^ Co Address l '/ ' T D N C-,7LC/'U,'/ , /`?C, 0 J WELL USE CONSOLIDATED WELL Domestic 2-�Public ❑ Industrial ❑ Type'of Water-bearing Rock Other Water-bearing Zones Method Drilled 2 1) From To 2) From To Date Drilled �a/& 3) From To 4) From To C� CASING a Depth to Bedrock Length I Diameter Type pv UNCONSOLIDATED WELL STATIC WATER LEVEL Water-bearing Materials i. Feet below land su�irface 6c) Sand: fine Elmedium,.Ej.\coarse0' Date measured VD DI S-F Gravel: fine❑ medium coarse❑ Screen: GRAVEL PACK WELL S ( , Slot# � length yti- from 90 to sy Yes ❑ - No ❑ Split Screen (or 2nd screen) WATER QUALITY TESTS MADE Slotxf lenqth from to Chemical ❑ Biological 0' Depth To Bedrock PUMP TEST Drawdown C? feet after pumping daysc) hours at AS__GPM. How measured Recovery feet after hours. LOG of FORMATIONS COMMENTS: (On well or water) Materials From To SC1 N 0 (i c) J(b A r DRILLER Firm r• CnrrivC'6d' �� Address6 .�nk AC, . City /tfn,��fce /Lra of 69 Registration No. cP,570 'operator s'�`ignature Pleas;print rirmly BOARD OF HEALTH COPY 25M-10-85.807101 Fps... ..... t. THE COMMONWEALTH OF MASSACHUSETTS ' �. BOARD. OF HEALTH. i ........ 1 1.....OF........ C ` .40ratiun for Uiiipasal Wariks Tuntrurtion Permit Application is hereby made for a Permit to Construct O or Repair ( ) an Individual Sewage Disposal Y S stem at: ~� ��1,2( o, __ Location Ad--ess �?^ or Lot No ................__......_............ --• ----• --•------ ...._..................... ..... W/2�owner Address -; _.. .. •........ ....... ...................................................... Installer Address #3 fo5 Z_ Type of Building � Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building No. of persons............................ Showers a YP g ---------•-----••-•-•------- P ( ) — Cafeteria ( ) d Other fixtures ...Z ... Desi Flow................ .�..�-J.............. lions per epson per day. Total it flow__.........�.........•.�.... ions. W P P P, Y Y ,1 ' W Septic Tank—Liquid capacity4�Q�gallons Length-..���....._. Width_ ,/0.... Diameter................ De th_. ( .._. P —I r- x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No...........1....... Diameter......1.n...... Depth below inlet........4�......... Total leaching areazAGt_?,:.!2..sq. ft. Z Other Distribution box (V) Dosing tank ( ) I-- Percolation Test Results Performed by � f"?�- . ' ..' ll_.t_.:..................... Date......�T?.. —� .,. --•• I............... ..... Test Pit No. L...._.:.—...minutes per inch Depth of Test Pit....... .r Depth to ground water._._... (i, Test Pit No. 2..�V __.minutes per inch Depth of Test Pit........J 3 B.. Depth to ground water..... a' Z:-.................••-•-----..-•-- —..•••-•••----..............----..........-..... - ------....._... ---- O Description of Soil......-- '_�..... / l! !E-1�-! �'' Al t ...... •�r - -�74�1J•_5 4_ly ►�+ �r _ � ) 4 /9.....�.�2 4 Gvf- ! a.fA��.� f -- ... v�. ( �`T cA.I•_�1" I+.., x ` .------ --------------------------------------•-•--------..-------_.--•---•----------------------------------------------------- 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:IT?• 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. Signed : 1............. ,( .�/.�_.......... `.. t...Date Application Approved By....................................... Date Application Disapproved for the following reasons:................................................................................................................................................... ............................. ........................../) Permit No.....-----•--------------------••--------.....------..__. Issued............................................ Date------ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........`T(..GtI.O.............OF....../?.19G 5..%�9�� ............................... Grtif utttr of Tomplittnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ()() or Repaired ( ) by.....L f: ).... L ...........................................•-••-.............................•--•-----....................._....---------------......._....--••-• k, Installer at...1-0 7........-?�y.....�E�-�ivCC�..... =n=l/�GS----------------------------------------------------------------•--...-----•--....----.. has been installed in accordance with the provisions of TI LE 5 of The State Sanitary Code A described,in the application for Disposal Works Construction Permit No._ _"Z,-7.2Y....... dated....... / j ............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................... 1...':..+..�...-• ............................. Inspector.......--------�y_._.-�..--•-----.............................-•--- ------------—---- ,-------- ----------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH 'mil/} �dlfJ. .............OF.......?/ge 5171 ..................................... r ..,....NO. -•�••...:!.... FEE......-.-�....._r i. Ropasal Works Tontnution Permit �� is C o� Permission is hereby granted----•./J----------------- L....._...-------------..._..------........._............-•------•---•---••---............._......... to Construct (/C) or Repair ( ) an Individual Sewage Disposal System at ................e...... /G C............._............. I / Street as shown on the application for Disposal Works Construction P it No(� , //Dated.._..li -;C.i........................ DATE. 4.n/� zt .......................•• Board of ealth �.11pIItSi?I ii?ITI(ITtT'tTjjjjiTlTllltiii!Iili(itlifiStilC?I!? ((t nilT•iiiir„:i*i"•,;'iu 11111i!iii'ii TimI!ii lilt,ti'iliFiiTMm IiltSPuLtuiIi'it?if(I;IIiiil(IiurliIiiTi!Ii' II i111IIiIMiIIiiililillilimm// ENVIROTECH LABORATORIES 449 Route 130 Sandwich, MA 02563 • (508) 888-6460 _ CLIENT: Bayside Building Co LOCATION: Lot 44 Regency Dr. ADDRESS: 1645 Rte 28 Bayberry Sq. Marstons Mills z Centerville, MA 02632 COLLECTED BY: D.A. Scannell SAMPLE DATE: 9/22/88 TIME: 12 PM DATE RECEIVED: 9122188 SAMPLE ID: ET 427 JOB #: New Well WELL DEPTH: 84 ft RESULTS OF ANALYSIS: Parameter Units Recommended limit Result = ;r 0 = Coliform bacteria/100 ml (MF Method) 0 pH pH units 6.0-8.5 6.06 ;~ Conductance umhos/cm 500 105 Sodium mg/L 20.0 14.6 Nitrate-N mg/L 10.0 .30 Iron mg/L 0.3 .19 Manganese mg/L 0.05 — i Hardness mg/L as CaCO 3 500 BE Sulfate mg/L 250 I Potassium mg/L 20.0 Alkalinity mg/L 200 Chloride mg/L 250 Turbidity NTU 5.0 _ BE: Eff Color APC units 15.0 BE. i` Background bacteria COMMENT: YES NO WATER IS SUITABLE FOR DRINKING PURPOSES FOR PARAMETER TESTED. xu ❑ DATE /4;;li:it!#F##li;lliiiititiilil#i##I3I is!1111i11J1i 131;31iliSJiliili#JJ1111K311311uIilillSSii33itui11i11ut1li3tuit331liliiNliu111ii3 its'#li#itul:ullutia!!ul+utus it!Ll it!!1!u#u###1,!#####!#1#####il it!a#aIU Ill#,ii,l!!u!##!!#illy V yoFTygro TOWN OF BARNSTABLE OFFICE OF aaaNAMs>:>s, BOARD OF HEALTH rasa 9w,e�i39- M 367 MAIN STREET 'ED ypY k' HYANNIS, MASS. 02601 September 22, 1988 Mr. John Bowes Bayside Building Company, Inc. P.O.Box 95 Centerville, Ma 02632 Dear Mr. Bowes: You are granted variances on behalf of your clients, Albert and Ruth Levine, to construct a well at Lot 44 Regency Drive, Marstons Mills, listed as Parcel 60 on Assessor's Map 64, 152 feet and 157 feet from the abutter's sewage leaching pits located at Lot 43 Regency Drive, and 135 feet from an onsite sewage leaching pit, with the following conditions: (1) The onsite sewage disposal system must be constructed in strict accordance to the submitted plan. (2) The designing engineer must be onsite and supervise construction of the septic system and certify in writing to the Board that the system was installed in accordance to his/her design. (3) Prior to the issuance of a Disposal Works Construction Permit, the well must be installed and the water tested bacteriologically and chemically. The water must meet all the standards established by the Safe Drinking Act. (4) This variance expires October 1, 1989. Very truly yours, Gro . M. 14t'r Chairman Board of Health Town of Barnstable GF/bs J J ; y ,� . 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