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HomeMy WebLinkAbout0072 RIVER RIDGE DRIVE - Health 72 RIVER RIDGE oG. ARSTONS MILLS - - -- _ A=059-007-002 r T_ Commonwealth of Massachusetts 6 9 00,-7 Title 5 Official Inspection Form Subsurface Sewage Disposal System Foray-Not for Voluntary Assessments 3> \Vttj --- P , e- Property Address LL I r �►rT� UY' �p/ '�G � Qi Owner Owner's Name ---�- L_ °_ L/ ! information s l , / required for every GrS Ks S Oo4 �Op 9 tO page. City,rrown / State Zip Code Date of WWtioh 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. Ynng out form A. General Information Bing out formr, on the computer, use only the tab 1. Inspector. ct r //1 key move your �cursoo r-do not �o use the return Name of Inspector Company Name o a Company Address�QS 1/ �a VoZ r�y/Tow 7�i State Zip Code ,Soy ado-- n� c �0-� Telepho Wnibe 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"CM5.000). The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority I ovq �U' Y ldt Inspect s Signature Date The s stem 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 DER 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. fiqris.3y 3 Title 5 official I spection Fart[sub-face sewage oisposm system•Page 1 of 17 �o VS l�� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments s Property Address 2Cr �Oi f ON ner Owner's Na 14 information is � required for every ArS�AS / i/��S �� 0�110�8 f c1 & page. Cityrrown State Zip Code Date 6f Inspection B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System asses: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CM 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for`yes "no"or"not determined"(Y,.N, ND) for the following statements. If"not determined,"please ex0ain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating t6t the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): Lyns•W3 Tide 5 Official lrspeefionForrtr SubsWam Sawege Disposal System•Fte2of17 Commonwealth of Massachusetts L Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments R►fie R� Address // �orTBati 0w ner ON ner's Name- information equirrequired for is requQedforevery page. Qy/Town State Zip Code Date of Inspbction B. Certification (coat.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):distribution box Is p ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a mannerwhich 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 t5rs•3%3 Title 5Official inspectm Form Subsufaw SM 9e Disposal System'Page 3of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9j- /ZVe Property Address / ON net Owner's Name required nation is equ A41140145 / i i�/S von �� rat 14 Qedfo page. CRy/Town State Zip Code Date 6f 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 sal 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 fleet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other. D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ 101-' 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%day fl ow Mrs.313 Title 50fficial I specton Forts Subwlace SevigeDispasel System-Page 4of 17 r Commonwealth of Massachusetts Titre 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 702 01 Vim►- ,�.��� �� Property Address Sol Ow ner Ouv ner's N3rne information is �G� /9 0) required for every page. Citylrown State Zip Code Date o Inspection B. Certification (corn.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or � obstructed pipe(s). Number of times pumped: . ❑ LJ/ 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. ❑ L'7 Any portion of a cesspool or privy is within a Zone 1 of a public well. supply❑ � Any portion of a cesspool or privy is within 50 feet of a private water pp y well. ❑ ;/*'�Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet m a private water supply well with no acceptable water quality analysis. [This from p pp Y 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.] ❑ he 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 CM 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or`no"to each of the hollowing, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes"in Section D above the large system has failed. The owner or operator of.any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Tito 5OfficidIre mc pee6onFo Sebswawsevmg Pa eDisposai sriom• ge5of17 tyre•3113 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forrn -Not for Voluntary Assessments ( � 1�IV-e✓ rz- St �d Property Address ( Owner Owner's Name /� !(S A14 information isrequired for every YS S / IQ 6� 0 a page. d —frown State Zip Code Date of Inspe tan C. Checklist Check if the following have been done. You must indicate"yes"or"no'as to each of the foil owing: Yes o ❑ ping 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): Number of bedrooms (actual): 330 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): tyris.3/13 Tile 5Offioial lnspectim F arm Subm rfaee Sewage Disposal system•Page 6 of 17 Commonweab of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments d- iZJ4'e- 12J Property Address li�/� oije ::,W Ox ner Qv ner's Narne �/J I/l information is GtrA nS / '/6`.f � N 6 -9 L! 0q /-6 required for every page. Cirtyrrown State Zip Code Date 6f Inspection D. System Information Description: �5//0 ,� 47( %ati Number of current residents: ,.. � Does residence have a garbage grinder? ❑ Yes B No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes No information in this report.) ,.,�^ Laundry system inspected? [I Yes No Seasonaluse? ❑ Yes No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes D-lNo Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM R 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t9ns-3M3 Tice 5 Dfficlai InapecGen Fort Subsuface Seerdge Disposal Sim•Page 7 of W Commonwealth of Massachusef s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 9a A~ (2..1 Property Address �01�a 0e, inf rintn ON oar's Name 11111 A14 l/a b` D h7144oadoo rftfn is / require r every page. tkyfrown State Zip Code Date of h1specOn Da System Information (coat.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: O-.ea'`'g a Source of information: Was system pumped as part of the inspection? ❑ Yes No if yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Altemative 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 VA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): 1 ille s official Inspection F armSubsurface SsW898 Disposal system•Page aof 17 tans•3113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address ON ner tun►ner's Name information is / required for ev A&,-5�o�S /6 � /,( page. Fd dwn State Zip Code Date of Ins tion D. System Information (corn.) Approximate age of all components, date installe (if nown)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron 40 PVC ❑ other(explain): �� r Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): ^ �� Depth below grade: feet 7ceda construction: oncrete ❑ 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: Sludge depth: 15M-3ff 3 Title 50fficial Inspection Form subsurface Sevege Disposal System•Page 9 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form e Not for Voluntary Assessments 9d vef, d Property Address Owner �� `�`� information is Ow ne>'s Name 1 / requiredforevery ✓5 49 el S / ��/� A4 page. atyf row n State Zip Code Date of I sWfi n D. System Information (cont.) Septic Tank(coat.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? de cA/Ge_ Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 9VVIOC) dl o 1 0�e,e- - Uoc7C' Cs� �i 7'�m✓/ , ::f �,S Grease Trap (locate on site plan): Depth below grade: feet I Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 15ns•3M3 Tive5official Inspection Form Subsurtaoe Savage Disposal Spbam•Page 10 d 17 Commonwealth of Massachusetts L Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address go/7L-P— ci L-1 Cw ner Cw ner's Nameinfornution is A.A"( �jrequired for every '^� A'//j 4 aa 6 LILT yk page. City/Town State Zip Code Date df 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 worldng 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 15re•3H3 1itie5 Official inspection Form Subue--IcsSeeggeDisposal System•Page 11 of 17 i" 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sew/a`7ge Disposal System Form s Not ibr Voluntary Assessments Property Address ff of r;e qLi ON nm n is Cw ner's Name � 7 ' // / requiinfored for every q�s "f �J A�l L11a 15� page. Ckyf row n State Zip Code Datb/bf insp tion D. System Information (font.) Distribution Box (if present must be opened)(locate on site plan): Depth of liquid level above outlet invert vtl 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.): � Sol s Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No* Alarms in working order. ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * I pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5rs,3M3 TifleSoffidal lnspeafianForm SubsWWO Sevrag MPOsal System•Page 12 of 17 f 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address L COwner D/ / e cc W natation is ON nets Name /m7� required for every °{ ✓�l /�� t/d 02 911,6 page. CSty OWn State Zip Code Date of Inspection D. System Information (cont.) x 6 1-// Type: leaching pits / number. ❑ leaching chambers number. ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching 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.): (--'0/ � I� q T �/ - S�� I � zlvt� 9 Yo� .-7 , S1 c:� L7 )/"dk Lv/I c- 64 f, Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No is m-3H3 Tide 5 Official Impaction Form Subsurface SavrageDisposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal Syste/.mForm -Not for Voluntary Assessments �/ rt / d- Y`n/!V�✓ �l p` Property Address 90 Af Ci L4 information is �^�ner's Name l required for every l�a-"S pf-s Allk Qa 6 $ a V 11 page. Lay/Iown State Zip Cod irate o 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.): dins-W 3 Tifle SOffiaal Irs pecflmFQnc Subsurface SewageDispasal%sham•Page 14 of 17 Commonwealth of Massachusetts vim Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Ow ner Ow nees Name inforrnadon is required forev ��rt *f page. iown State Zip Code [We oWarpection D. System Information (cons) Sketch Of Sewage . posal System: Provide a view of the sewage disposal system, including ties to at least two anent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where p c water supply enters the building. Check one of the boxes below: hand-sketch in the area below drawin i Fr. Al 147� - �3 �� - 3/ a Cove, 15ns•3/13 Tide 5 Official Inspection Fara Subsurface Sewage Disposal System•Page 16d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner information is owner's Name /�j� /- required for every _2 a rS�KS // "/'/U 4 1-f a q- 1'6 page- own 5A State Zip Code Date of n Do System Information (cost.) Site Exam ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water feet Please indicate all methods used to determine the 9 high round water elevation: ❑ Obtained from system design plans y g p a s on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Zo 15 L kve - d t.- � �t � � ✓ter r�-� li �- l0 / �e law � �� , Before filing this Inspection Report, please see Report Completeness Checklist on next page. 1.5m-3%3 TU50ffidalinspeofionFamSuMsfase eDi ma S Sevrdg SP ystem•Page 16 of 17 r Commonweafth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address 12o/ �-eC-Li ON ner ON ne's Name / y� � rfomra 1 fore�vety is requ�edfo a S rS A��S /Y4 - (� -- page. atifrown State Zip Code We of lnsp'=ti E. Report Completeness Checklist L`1 Inspection Summary: BCD or E checked B inspection Summary D(System Failure Criteria Applicable to All Systems)completed Ly'Sy em h*rmation—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 6M—M3 rde5OMW lMpwdcnFC=SIDWI O Sfteposspow so m•PAP V d 17 i f Commonwealth of Massachusetts Title 5 Official Inspection Form VVjSubsurface Sewage Disposal System Form -Not for Voluntary Assessments �)- (-�i ve✓ /�?l d ,Q - Property Address 199/ � VG Ow ner NOW ner'q Name , SG►1 /eS�✓� e�/ information is required for every page. City/Town S—tatGel— Zip Code a Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered In any way. Please see completeness checklist at the and of the form. impooutforms rm A. General Information filling out formss on the computer, use only the tab Inspector key to move your I / cursor-do not / / use the return ar O /e//l key. Name of Inspector _ Company Name 0 / Company Address � .S l�l l�✓J 00 � ?ow" State �� Zip Code Telephone Nu VWeT 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: "es ❑ Conditional) Passes Y ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority � Inspec is Signature Date /81� j 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 god or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DER 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. t5ins 3113 Title5officlsl lnspectlonForm Subsvfam SevM9Diepoeel System.Pape 1 of17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '7 vev� A� � 1,il- RopertyAddress c Ow information Is ner s�"� I required for every 4/S7ro✓!s �S od��(,Q /8 /� page. City/Town State L Zip-1�Code -- Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) Z�l asses: have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System conditionally Passes: ❑ One or more system components as described In the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. . Check the box for"yes", "no"or"not determined"(Y, N, ND) for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old"or the septic tank (whether metal or not is structurally unsound exhibits ) turall substantial infiltration or y exfilt ration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and If a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ NO(Explain below): Ons•W 3 Title 6omial InsPecton Fantt$ubewfwe Sewage Disposal$yetOm,Page 2of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 904 I�IVer Property Address OW ner ON ner's Name formation is 1 I/l OU 6� /� � ( �quiredforevery �► �J page. Wit" State Zip Code Date of IrApection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): i r C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 16.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh O"e-3H 3 Title 50fedd Inepecdon F orm Sut meme Sewepe Diepaeg System•Pape 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Font -Not for Voluntary Assessments Property Address / CW ner C 14 iteS i ®r Information is ner a Name required for every �rj�o✓1 f ji///�� �/�� �� (F Wctlon page. �tyRownState Zip Code Date f oIn B. Certification (corn.) 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 t50feetor . ore from a private water supply well"". PP Y Method used to determine distance: This system passes If the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other. D) System Failure Criteria Applicable to All Systems: You must Indicate "Yes" or"No" to each of the following for all Inspections: Yes No [] Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool [] ®/ Static liquid level in the distribution box above outlet Invert due to an overloaded or clogged SAS or cesspool [j Liquid depth in cesspool is less than 6"below Invert or available volume Is less than day flow One•3/13 Tide 6Of8del ins pecdonFern[$uheurface S"oDispooN gYMm,peas 4of 17 i Commonwealth of Massachusetts Title 5 Official Inspection FormRUIUW m Subsurface Sewage Disposal system Form -Not for Voluntary Assessments Property Address-22L— /I i1ek- �� Ow nor ON ner's Name G Inforrnatbn is required for every ����o tiS page. page. Gly/Town State Zo Code Date f Ins tion B. certification (cont.) Yes No 13 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 Beet 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. �I 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 6 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&, I have determined that one or more of the above failure criteria exist as described in 310 CM 15:303, therefore the system falls. 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 16,000 gpd. For large systems, you must indicate either"yes"or"no'to each of the following, in addition to the questions in Section D. Yes No ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes"In Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall de the upgra system in accordarce with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Ons•3N 3 Title 5 0fseial IrO P900on Form SubstOW0 SOVMO DIspoW System•page 5 0f 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for VoluntaryAssessmen is i�l l/e!� �► c� �il ram. Property Address Qrr nor G lee/ ✓1 Information Is �^'nor s Name required for every q Ire,4.14 S i� page. WfTown � !AA-- --4 g tip Code Date f Ins tbn 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 B ,/ p card of Health ❑ u 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? u ❑ Were the septic tank manholes uncovered, opened, and the inte rior 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)1 D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: gpd x#of bedrooms): ��� : thins•3/13 Title 5 of5dsi ins pec tiro F orm:Subsurface sewage Dispose,System•page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage DisposaI System Form -Not for Voluntary Assessments 9d Miler Owner �� Property Address information Is Ow nor s Name required A/s �✓J page. page. O►ty/Tow n A 16L—�'4 State Zip code :]CMitelins; tbn D. System Information Description: /Voo/ Ga//oN r 7 YI "J[q�fo 1 A --------------- Number of current residents: j Does residence have a garbage grinder? ��No El Yes L7 Is laundry on a separate sewage system?(Include laundrysystem Inspection ,. � information in this report.) ❑ Yes L�.!" No Laundry system inspected? ❑ Yes L7 No Seasonal use? �,� t� Yes Ll No Water meter readings, if available (last 2 years usage(gpd)): Detail: Sump pump? ❑ Ye " No Last date of occupancy: is Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: On-3113 Title 5 oMciai iropecoon Form SubSUfmo Sewapa Olsposel SyMm.Pape 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address C'"nor Owner's Name information is required for every �!S h S /� Od. 4y page. Cily/Town State Zip Code 0 pecton D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of S m: 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/Altemative 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 VA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (descd be): t9ro 3/13 TI0e5OMGalImpeebonFormtSu"aceSewageD1e150601Sys1em Page eof17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface 89wage Disposal System Form -Not for Voluntary Assessments Property Address veli— Ow nor Ow ner's Name G�les I .P✓ Informatlon is ✓ page. for every City/Town 1,11,1'r ./ I Wsn State ZipCode Date D. system Information (cont.) Approximate age of all components, date installed (if kno )a source of Information: Were sewage odors detected when arriving at the site? ❑ Yes N[� O Building Sewer(locate on site plan): Depth below grade: feet Material of constructi;40 ❑ cast iron PVC ❑ other(explain): Distance from private water supply well or suction line: / feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 'Depth below grade: C) feet 7cerl c onstruction: :oncrete ❑ metal ❑ fiberglass r9 ❑ 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: )(� Sludge depth: t5rb•w 3 Title 50f11cIaI Iropecim form subsurface Sewage Dlspaeal System•Baps 9of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not four Voluntary Assessmen91 vie-K ts Property Address ` les r e K Owner Owner's me �J p information Is required for every page. City/Town State Zip Code Date of±smtbn D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness ' " N Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Pie Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 6/ �+� �/ 4�►d � /v1 GjOu _ p r+�/7`to A4 4XV �f Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t9ns•3/13 Me 6 Weld Ins peebon Forrrt Subsvfaoe Sewege 04spoo System Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �l��'"✓ 11 L G �lJ/l✓'�i Property Address -S6 - Iles I✓t Info ner Owner's Wama / ,f/J tij O�/ Q / / require fo b Qrf KS /�/ �� 4� O required for every � page. City/rown State Zip Code Oag 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): Dept h bel ow 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 One•W13 Tile 50redel Inlpeceon Form Subeulwe SmAgeDiepoed System-Page 11 d 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments /�) 4"9 40 ivy-, Property Address �G />7 CCforrrlatlon Is ner 0W ner's Name required for every _ page. City/Town State Zip Code Dat of I Y / D. System Information (cont.) pection Distribution Box (if present must be opened) (locate on site plan): Depth of liquW 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.): i411b So l e& if Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No* Alarms In working order. ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not In working order, system is a conditional pass. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t51ns•3113 T1095Offloid Irepec5onFam Subsurtace Sewage DIspoW$ptem•Begs 12 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewag�e Disposal System Form -Not for Voluntary Assessments / Roperty Address // Y—C' h /eS h Pr ON ner Oar ner's Name Information Is required for every a✓r�Nf / /��� Dd qly �f $ page. Cdy/Town State Zip Code Ntabil Inspection D. System Information (cont.) Type' leaching pits � number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching 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.): �i Oki ell H Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to Inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No One•3+13 Tide SUMS IrmpectlonForm Subsurface Sewage Dls csel S p yelam•Pape 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for voluntary Assessments / , ver- t C/ e Property Address Owner Owner's Name /Y! 2r� information Is7 required for every T,,,, , page. Cnyrrown State Zip Code Dete 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.): U t5ns Y13 TiOeSOfAclal IropecknForm Subsulacs SewageDisposa System-p49e 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �l l�l� �� C Properly Address 20� 1G ��S 1✓I 2 O.v ner Ox ner's Name information is / requiredforevery page. City/Town State Zip Code Dati-WE3pettloh D. System Information (cont.) Sketch Of Sewage Disposal System: Provi de a view of the sewage disposal system, Including ties to at least two rmanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where lic water supply enters the building. Check one of the boxes below. hand-sketch in the area below ❑ drawing attached separately GAi4 f.4, Flo d a3 a AJ - 30 YK 3 taro 3113 Tile 6Offleid ire pec0an F orm Subs OW8 S"O DOOM Syeiem•Page 16 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments vlev �► e �i i v� Property Address Om nor Ow ner's Name required for every A-14y-r�0-7f.. page. City/Town State Zip Code We Inspe ion D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells i Estimated depth to high ground water. 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: pate ❑ bserved site(abutting property/observation hole within 150 feet of SAS) Checked with peal Board of Health-explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground "�r elevation: Z0 7`- If ���v o-, v e� •— & AVt7 07-'- ��� /o /o t✓ �a de Before filing this Inspection Report, please see Report Completeness Checklist on next page. t9ns•TO Title O(fldd IropecsonForm Subsurfeoe SewegeDlsposd Syuem-Page 18 d V Commonwealth of Massachusetts Title 5 Official Inspection Form ROM 9 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments /��L lQi t�Gy 4' Dj f ve Property Address / '— Sc ! IeS t ►'1 I Owner Owner's Nainformation is me I required for every i' " � �'✓Y�✓'I j' -<�`S A✓ 0114�G� page. Cllyf raw n 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 Q'Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file tans•Y13 T1Ue50fftc1AInspecUcnFarmSuDs weSewage0lep0WSystem•Page 17d17 �oF.►�rgty Town of Barnstable P# % 0 2- 9 Department of Regulatory Services • DARN6TADlb, e r '� -r" E: �x Date a MA68..,, $ �,! '.Public-Health-D.lvlslon' .ego K .H rEo Au t► I; I 200 Main Street;Hyannis MA 0260I h � - _ ...... -• � : . .� 3/ Time D;vJ -_Fee Pd.._._ ,�� _ _ •< Date Scheduled — '- J �" Soil Suitability.Assessment for Sewage Disposal Performed By: ID S S on r9 Y� Witnessed By: Q�C/ B ffiiN S•r7M t.tr- HLYrL:T_H) !� II�Ni991 ItI N IVIi��ll . i 4. u i I� �11NII@ d,af�ll�di..�liiiVmlNJili(� +: 1 Ndi il � Location Address a Rivet- t- p�� Owner's Name R�g�T L R�� l K I` + �o I r►+ MIKIrJR CP.L,Orz). M . �„rll r Address Engineer's Name 5 .D1-3 I!w Assessor's Map/Parcel: I�'— (�..d � g NEW CONSTRUCTION REPAIR Telephone It �` ��� Land Use V��'TI �}Ci Pt GUC.-?t ft Slopes(%) Surface Stones' Al /NICE (04 D Distances from s•,Open_Water Body.J>,7Q� ft',.Possible Wet Area ft? Drinking Water Well ft ft I Drainage Wa ? ft Property Line S' p It I Otlier SKETCHs(Street name;dimensions of lot,_ezact'lotatI6nS of test holes'&pere-tests,!Iocate wetlands-in proximity-to holes). f t X t 6 0S `� I I O cc1 Ii ••r-• t j ® •• ............ ' I ce Parent material(geologic) V ACiA-L ouytyArS R Depth to Bedrock PtaT L Cc"' Depth to Groundwater: Standing Water in Hole: N 0 Weeping from Pit Face Estimated Seasonal High Groundwater11 i �t I ' MI. ��' OIL, I,It�, 1111 Method Used: Depth Observed standing in obs.hole: In. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well to Reading Date: Index Well level Adj.factor Adj.Groundwater Level— I a � lil i�yl.•, Observation Hole It Time at 9" Depth of Pere 2 , = Time at 6" S ... Start Pre-soak Time® •< .. Time(9' 6 - End Pre-soak )0 3 5— AM Rate Min.Mch Z ., .P-� Z 4- 6KLQ,,)S Z— �.5� M1I M'-C' : Site Suitability Assessment: Site Passed V Si,-q Failed: Additional Testing Needed(YM) Original: Public Health Division Obs4vation Hole Data To Be Completed on Back---------- Q:HEALTHWWP/PERCFORM ........ � `L gu�!��I:�!ilflli�li1J�111�' �" .'�I im Depth from Soil Horizon Soil Texture So ,Co ror So 1 O 15 , �;, ! i Surface(in.) (USDA) (Munsell) Mottling Structure,Stones;Boulders. {7Consistency.°o 06Q S, LvAYA 0 /�. _ J o yf .s3 B poYt H4- M.5AWD GI 2-•Sr Gn-Atez, )r:�- s0q1V,0 C-Z- ?. sY /4- I f ! yr,: ! dilly! 1.1 ..: ilfur yl, �,d bi. N I! �: ' � k In' a M., IM' .. -III! '�,!.. i J I�Id�i ...... Depth from Soil Horizon Soli Texture Soil Color Soil - Other Surface(in.) (USDA) (Munsell) Mottling Structure,Stones,Boulders. Consistent %Gravel 19 2-1 r I ��ttll�' 'tlh��ll �h!!I G .�1h9 . g. �rd. ..li m . wwa{ , _ Ii.4�I�Iisa .I.r, 6i...... ,II i 14 .IIIf��Ililu!II. I,,I'ill(il: Depth from Soil Horizon Soii Texture Soil Color Soil Oihcr Surface(in.) (USDA) (Munsell) . Mottling Structure,Stones,Boulders. Consistency,%Gravel) III �•nl !I!:.. 111. Vl,�VpVI)�:I!III,Ii,I6Nd l hu!!I,!il d��aat�hfbF9ill;,Pil�9u;(�1PJ'�6"dIN-� !Nm,Kk !; , `. Depth from Soil Horizon Soil Texture Soil Color' Soil - Other Surface(in.) (USDA) (Munsell) Mottling Structure,Stones,Boulders.' Consistency.%Gravd) Flood Insurance Rate Map: Above 500 year flood boundary No— Yes V Within 500 year boundary No Yes Within 100 year flood boundary No_ Yes Depth of Naturally Occurring Pervious Material Does at least fourfeet of naturally occurring pervious material exist in all.areas observed throughout the area proposed for the soil absorption system? Yk S If not;what is the depth of naturally occurring pervious materialV- Certification I certify that on /.iS , �/ '(date)I have passed the soil evaluator examination approved by the., ; Department of Environmental.Protection and that the above analysis was performed by me consistent with the required training,expertise and experience described in 310 CMR 15.017. Signature d S Date 7 I a2-- Q:fIEALTH/WP/PERCFORM �oF414E Town of Barnstable P# J Z 9 z- Department of Regulatory Services BARNs'uBr.E, �_ Public Health Division Date ��°lEo►auk�� 200 Main Street,Hyannis MA 02601 Date Scheduled �. 3i U 2 Time m Fee Pd. Y Soil Suitability Assessment for Sewage Disposal Performed By:. tV S S D G J (t r 2Y) Witnessed By: D�V j B it�ry li. itw..�,Lull' I i�.'. � i r.,D� r.,��� ..� m� iE ��:•n0.1 s ! I! k ! IW ...il!!�•fl' I' it,�k� Ig114!I# j�l._ . ,�� � I+I�I1xP � �' d �{'rl,,!'I�i t �i 1 } � �'�! ! �rll�I 'IIIIIiIY. 1 YJM a ,L ,.I i ,1 i 1 I kmI11 �111i i�pp��f 'IIII!�O�V I '1� AI Iil(@f"ItM1 � q� it i i' I:Id:tli 4iX n.. !d IWiI t 4...._, Location Address -7 �1 ut"r n_p� Owner's Name ADSM-f LF}rl 1��1 t 0 I ►+ MI KINK P-1.0�3) o r /V) . �i�ll s Address Assessor's Map/Parcel: D Engineer's Name 5S DL-3 I& i NEW CONSTRUCTION _A/ REPAIR Telephone# I I Land Use V�f-�► ?��l�G¢t WG7 Ai,Slopes(%) 0-1 Surface Stones At© r`►it.L 104O '''� Distances from: Open Water Body' 7PQ ft ,Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&pore tests,locate wetlands in proximity to holes) 0 1 I v � j 1 pmt--i- ®Z x, .�...- , j t, r .sus x rkra' 3:Kta siS ,l••�q Eria94 ; y 4 J�.� Lr } Parent material(geologic) 6,C AC i PAL our%W RS R Depth to Bedrock Pf'91— (yJC",-M-Y 4i'O, Depth to Groundwater: Standing Water in Hole: 0 Weeping from Pit Face 10 0- Estimated Seasonal High Groundwater 0 / +r:::�tr ���li.. 'n��r 4�IiiIR'iI1JI,y!ill`ki'i'I'�!�}!����`;5',9fiji!� N II i�i UI, !1'ullgl�it I t.; a r 4$ h i I 9 �2:IJ,ii 4u:nu LIa a mA I ca do:w•Im.w.1, Ilnq.c. a .i. x x tl�:ik''4y411h Method Used: Depth Observed standing in obs•hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor . Adj.Groundwater Level— W r Ci�, ' i t I FJ�d�i� ImyXi M q3. ' OW X, tiNliXidX I I �. I. Observation Hole# Time at 9" ' �2• I � ... Time at 6" Depth ofPerc._-..; '__._ .. .__._ ._._ �. . _ .__._ Start Pre,-soak Time:®_ ", Time(9_.6.)a i End Pre-soak RateMin./Inch•a_ _�_ •�—�' .Q,�. &ALLai, $ � � 5� MIS S .. _ Site Suitability Assessment. Site Passed V Sic Failed: Additional Testing Needed(YIN) Original: Public Health Division Obs4vation Hole Data To Be Completed on Back--- Q:HEALTH/WP/PERCFORM x � � � x4 is rCR !�hL �nI pFxi A 7r I t ° la�iill Gll r 'I6 iII`ppp i l'I'I�I IIq!Itl ,A , .., ,.. .ly;�� tld1011�!I�IiflI IIIIIAN� I: I 'APt lt.'Y •�'Wf 7 ., : ! M I i.1! I MI III, IIIIAIIIIIIINIIU�'�II�Id4 , Depth from ~~ Soil Horizon Soil Texture �+50 - o or„ z,. i o I t7ttor �?/ Surface(in.) (USDA)i (Munsell) , Mottling Structure,Stories,Boulders. consistenev,"% ravel 6-9 G t� !o y�2 S g 2,4-44" Gl M- 54..Jo ?-.Sy 3/4- ��F-►IS�r GZ F• s�9 2•Sy �� P1. ,. y I,!!I 71 I 191i rY!fqq'�1� I k�fj F ,.I 5 <.- i ,y f i I 1 N!'` a�t A41'� Ili R JA;!46i69v iI lUdl �., [ h.. Y 4' .. .i'M. �l}7. �Ii,P iL.,,, i. c'G! .J Idii'IYI Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling Structure,Stones,Boulders. Consistency.%Gravel S.L,oAV--A /tsY2 1 -3 u I I � :,, � x !' .,i� � ' �, .I ,. 'I v �r��'Q 1 I II"'�II�I'� Ij;,Il j:nl�,I1•I,x II•!I�,IPIj?{, . �' P! k.I' 'Ikl,�(IJ, I4r�,� � aJ "%.IN6t�Tr!+ µ pis.F.. !�i.kfilrl 1!RluTJ l I,*9...4 h IIiIII���Y SlEili .�lh i I!...'.. I �I .IINHUIIN.Illfdl�lli 'ii�I'IIiII�IfIbNI�111!t6 !.IA hll.5il,,, W' - Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling Structure,Stones,Boulders.. Consistenc %GCRveI �( 1 III �Illl ,.1161 I I"�IIIII!I'iPi ' . I'I'p a ! t I qi t T Ir�,Ijt I��1�II,�I 7 i ^'1 i y - I,'I Iggg���I ' �''ilNill4!W16�1i �! ,9! rr r Ir hl 9 I U ,1kAJ. IIIIIYIf�y llJ!:fl!U 'tl 1 U�.. .��Ii�ll�lllnll.I.i IIII�,�IIII�JJ.,liiilIh Depth from Soil Horizon Soil Texture Soil Color.... Soil Other. .... Surface(in.) (USDA) (Munsell) "Mottling.... Structure,Stones,Boulders., Consistency.%o GravO) Flood Insurance Rate Map: Above 500 year flood boundary No T Yes Within 500 year boundary No Yes Within 100 year flood boundary No _ Yes Depth of Naturally Occurring Pervious Material i Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? _ If not,what is the depth of naturally occurring pervious material? Certification I certify that on /o 98 (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me.C6nsistent vrith the required training,expertise and erience described in 310 CM. R 15.0.17. - Date7 31 d'L Signature • Q:HEALTH/WP/PGRCFORM oFi►a<rq Town of Barnstable Department of Regulatory Services _ ": wF ;Public Health D><v><s><on +_ Date 7 . 200 Main Street,Hyannis MA 02601 f r.r: i Date Scheduled 3i •U Time y D:Od nn Fee Pd.��_ + Soil Suitability Assessment for Sewage Disposal Performed By: 4�2) Witnessed By: D�V Mt'N S TIN�h w— HLn—,L;T-8) I niI' lii i4 li' ii '11R, �,1 'I. I 111N '.. ilt f' 'r✓ul ll� IV'��'161� I'i I Location Address n R� Owner's Name Rogue-r IC�ve/� + �n I r►+ MtKItJR i CP--0T-4-) M . v1„ Address Assessor'sMap/Parcel: 17—o I Engineer's Name BSs D(.,3I& ^ NEW CONSTRUCTION REPAIR Telephone# SZ 8 540 88 d Land Use _.. V6C"'T-rAG hi wC-jtAAt; Slopes(%) Surface Stones Ato Distances.fromi.,_OpeW n ater Body, u ft Possible Wet Area& ft Drinking.Water Well < n i s I L d `�5 _` ft._�_Property Line S "I ft Other_ ' 8 ; • SKETCH:(Street name,'dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) _......----........ ----—---- --- Z 4 4-, 1 I t t t � t 0 � I �a3 1 i Parent material(geologic) (;LAC 1►NL Uu•f ^S R Depth to Bedrock &ejl— LW ULW I-0' V'O Depth to Groundwater: Standing Water in Hole: NO Weeping from Pit Face /J Estimated Seasonal High Groundwater. (�P[Wpp�'[ Ry•�1),�'�8IllJ'�Y;l�ipll�'i ��jtiI�III�tlil��77 t. .. { p:, i a�j', t i:i dOEM. tl l 6 N� 1 a�4f Method Used: Depth Observed standing in obs.hole: in. Depth'td soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well 0 Reading Date: Index Well level Adj.factor . Adj.Groundwater Level_ t. '' " il'24'�IrJ: 011 �I '11,1 111 .•y lli �;:,yil l��, l �I I 1 , q,4 B. cRry t Observation Hole# ��.�,,.. Time at9". =LL— Depth ofPerc l0 2 Time af6" Start Pre-soak Time J O 2_s 1 ; ; Time(9 End Pre-soak 1 U 3 5- AM Rate Min./Incli M •P Z,,.+ aAL L O,3 S G: -IS', M/nl C. c. Site Suitability Assessment: Site Passed Y Sl p Failed:c- Additional Testing Needed(Y/N) 1 Original: Public Health Division Obself'vation Hole Data To Be Completed on Back----_�__ Q:HEALTH/WP/PERCFORM , ... , , P. _ tlfl li �.. 1 I I I'. :�':n,. .'' ,n ,�� •�� � 'I,N : I� �M� rllUll!i91�1'I N l�lud ,la!.�C..Ar' AN 4�NOW, lfiN��. r IUU I I I, I�I�UIiI Depth from Soil Horizon Soil Texture , Soil.Co or, Soil Surface(in.) (USDA) (kunsell.) _ Mottling Stnioture,Stories;8ouldeis. Consistency.%Gravel Ld� 1aY2 S3 /Z-3 2'1 Q L°�++�t [,o ye- /g nvv 3 z-s3'r C I 5 r+l%to Z rY Y+ /fro 5-3-12 0" CZ F f il.'ll.4D 2-5-1 W D N J i Ill l 1� 14 �I Ni '�li.IOIa I U I: , ' .� ,. � , ;I i k �J ��I. h�.u�� il' N 11dbN ii tl'....I! I��I'J�:i�l IIVI�I�IiIU.illlRlllb.�ll�Il!4� Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling Structure,.Stones,Boulders. Consistency,%Gravel 0-8 A- S . LpV 16)! /JO O , 7 Ir Jur FJ!�l � SRON� I'll'!! d� . 5 rt 11, 1, I m SI GoPo�Ii li I I t hI�eIIrDepth fro Soil Horizon Soil Texture oil Color Surface(in.) (USDA) (Munsell) Mottling Structure,Stones,Boulders. Consistency.%Gravels_ i�N� � i,� 1 � r V � OR', . 111111 u I I In�l ' III•ylr rlt tYln4�,I iU..,' li .�• "'' }t . ! ' I� �a,ucl+pitlUi,INU,'Idll,l`�L, .ulOY iN!N, " „t 11 I ► ,�'� Iri�l� +' ,hr: IA:'E 1 � :�hll G .�:1'U•...,,.. 9y itl!al:P.UI:,LII IGll1,i'kl�l'Y Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface,(in.) (USDA) (Munsell) Mottling Structure,Stones,Boulders., Consistency.%Gravel Flood Insurance Rate Map: Above 500 year flood boundary No- Yes V Within 500 year boundary No_ Yes Within 100 year flood boundary No_ Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? If not;what"is the depth of naturally occurring pervious material?"" I Certification I-certify that on D . 8 (date)I have passed the soil evaluator examination approved by the , Department of Environmental.Protection and that the above analysis was performed'by'n ie'consistent with the required trainin expertise and a erience described in 310 CMR 15:017. Signature Date 31 D7r Q:HEAI.T /PERCFORM `+ TOWN OF BARNSTABLE LOCs► 'ION SEWAGE # VILLAGE ASSESSOR'S MAP LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) �y 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 Lekhing'Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Weiland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by a - n 7 o A 6 RANI �B a3 Ac 3b In COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS z DEPARTMENT OF ENVIRONMENTAL PROTECTION v t Y TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 72 RIVER RIDGE.RD MARSTONS MILLS,MA 02648 -I" Owner's Name: COVINGTON Owner's Address: 72 RIVER RIDGE RD MARSTONS MILLS,MA 02648 Date of Inspection: 2/8/01 RECEIVED Name of Inspector: (please print) JOHN GRACI Company Name: SEPTIC INSPECTIONS F E B 1 s 2O O1 Mailing Address: P.O.'B�D�C�2119 TEATICKET,MA.02536 TOWN OF BARNSTABLE Telephone Number: 508-564-6813 FAX 568=:564-7270 HEALTH OEPT. 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 An'd maintenance of on site sewage disposal sysiems. 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 Inspector's Signature: Date: 2/8/01 The system inspector shall submi a copytof 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.d zign 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 t6 the buyer,if applicable,and the approving authority. Notes and Comments ''` THE SYSTEM PASSES TITLE V INPECTION. RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE: RECOMMEND RAISING COVERS FOR PROPER MAINTENANCE. ****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 `'. . w;s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM f_ PART A 4¢` , .I CERTIFICATION(continued) . Property Address: 72 RIVERAIDG'-E RD MARSTONS MILLS,MA 02648 Owner: COVINGTON ' Date of Inspection: 2/8/01 / Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Sectflun D 1, �.��t A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE.RECOMMEND RAISING COVERS FOR PROPER MAINTENANCE. 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. s. Answer yes,no or not determined(Y,N;ND)in the for the following statements. If"not determined"please explain. K'c n/a 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 ass inspection if the existing tank is replaced Y P P g P 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. f a:F ND explain: n/a ; ,J n/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 +"r Health): _ broken pipe(gYare replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass r inspection if(with approval of the Board of Health): _broken-pipe(s)are replaced `s _obstruction is removed ND explain: n/a Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 72 RIVER RIDGE RD MARSTONS MILLS,MA 02648 Owner: COVINGTON Date of Inspection: 2/8/01 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 Boardof Health determines in accordance with 310 CMR 15.303(l)(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 y'• 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 n/a x• T "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: n/a i 1 '� Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 72 RIVER RIDGE RD MARSTONS MILLS,MA 02648 Owner: COVINGTON Date of Inspection: 2/8/01 } D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for alLinspections: 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 '/2 day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped nla. 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 eoliform 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 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 desiga 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 m addition to the criteria above) yes no X the system is within 4.00 feet of a surface drinking water supply X the system is within 200 feet of a'tributary to a surface drinking water supply X the system is located in a'n'hiogen 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 ; t 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. . a A Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM £ ' PART B r. CHECKLIST Property Address: 72 RIVER RIDGE RD MARSTONS MILLS,MA 02648 Owner: COVINGTON Date of Inspection: 2/8/01 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system'components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? ".x X Have large volumes of water been introduced to the system recently or as part of this inspection? �=t .1. 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.? t; F t X _ Was the site inspected for signs of break out X _ Were all system components,excluding the SAS, located on site? . ti X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the battles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? , X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no 4 X Existing information. For'ezample,a plan at the Board of Health. y X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is ;`. unacceptable)[310 CMR 15.302(3)(b)] !S ty j u S Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM 114SPECTION FORM PART C SYSTEM INFORMATION Property Address: 72 RIVER RIDGE RD MARSTONS MILLS,MA 02648 Owner: COVINGTON Date of Inspection: 2/8/01 ,,:FLOW CONDITIONS RESIDENTIAL ` Number of bedrooms(design):3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330 Number of current residents:2 Does residence have a garbage grinder(yes or no): NO 3' Is laundry on a separate sewage system(yes or no): NO' [if yes separate inspection required] , Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)): n/a Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIALANDUSTRIAL, Type of establishment: n/a Design flow(based on 310 CMR 15.203):n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to`tlie Title 5 system(yes or no): NO Water meter readings, if available: n/a a Last date of occupancy/use: n/a f OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a °2sa Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a 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) _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): n/a Approximate age of all components,,date installed(if known)and source of information: 1989 Were sewage odors detected when arriving at the site(yes or no): NO r, Page 7ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 72 RIVER RIDGE RD MARSTONS MILLS,MA 02648 Owner: COVINGTON Date of Inspection: 2/8/01 BUILDING SEWER(locate on site plan) urn, Depth below grade:30" Materials of construction:_cast iron X40 PVC other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 24" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no):NO(attach a copy of certificate) Dimensions: 1000G L 8'6" H 5' 71" Wa 4' 10" Sludge depth:3" Distance from top of sludge to bottom of.outlet tee or baffle:31" Scum thickness: I" 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: n/a 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.): THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. GREASE TRAP:_(locate on site plan) ` Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a , Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a f t iF a at.y 7 i Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 72 RIVER RIDGE RD MARSTONS MILLS,MA 02648 Owner: COVINGTON Date of Inspection: 2/8/01 ; s; r TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO ` Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:X(if present must lie;opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): STRUCTURALLY SOUND !` PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): NO E Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a i i l t f" i R Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 72 RIVER RIDGE RD MARSTONS MILLS,MA 02648 Owner: COVINGTON Date of Inspection: 2/8/01 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,darhp soil,condition of vegetation,etc.): THE LEACH PIT IS STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING PROPERLY. CESSPOOLS: (cesspool must be purr,ped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a i Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 72 RIVER RIDGE RD MARSTONS MILLS,MA 02648 Owner: COVINGTON Date of Inspection: 2/8/01 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. 3 Gcx- . � F . A g A AA it la g At 3° p AA � a1 31 in Page I of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 72 RIVER RIDGE RD MARSTONS MILLS,MA 02648 Owner: COVINGTON Date of Inspection: 2/8/01 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet . Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a NO Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators;installers-(attach documentation) YES Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: USGS MAPS AND CHARTS- 12+FEET c s i� �^ C P - s C1 TROY WILLIAMS SEPTIC INSPECTIONS . t APR6 Certified by MA Department of Environmental Protection `J� 8 ajTge(E (508) 385-1300 19 Hummel Drive South Dennis, MA 02660 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION COPY ONE WINTER STREET. BOSTON, MA 02108 617-292.5500 WILLIAM F.WELD Governor TRUDY CORE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION Property Address: 7 2 D i v er Z cl q c. Dr /0 II S. Address of Owner: Date of Inspection: y1� /98 GeO y` Va T r o W i l l i a m s (If differenU ✓ Name of Inspector: y 7.2 je;,1:, 1 am a DEP approved system inspector pursuant to Section 15:340 of Title 5 (310 CMR 15.000) Company Name: Troy Wi IV Septic Inspections Mailing Address: _19 Hummel Driyp - SAuth flannlSs MA 02660 vaCy�} Telephone Number: (5 018)_3 8 5-13 0 0 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: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: J �o L+ /N ,y sig Date: 8 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: AJ SYSTEM PASSES: VI 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. COMMENTS: BI SYSTEM CONDITIONALLY PASSES: A 119 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. _ The septic tank is metal, unless the owner or operator has provided the system inspector whh 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 conforming septic tank as approved by the Board of Health. (—i—d 04/25/17) :' P.Q. I or 10 P SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 72 River Ridge Drive,Marston Mills,MA Property Address: George Valliere Owner: April 2, 1998 Date of Inspection: B) SYSTEM CONDITIONALLY PASSES (continued) A1119 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). Describe observations: 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 C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: A1119 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 MANN WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: ER 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, IT APPROPRIATE) 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 to 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 (approximation not valid). 3) OTHER SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 72 River Ridge Drive,Marston Mills,MA Owner: George Valliere Date of Inspection: April 2, 1998 D) SYSTEM FAILS: A/ You must indicate ei;,.er "Yes" or "No" as to each of the following: 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. Yes No 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis., If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No _ the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area-IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST 72 River Ridge Drive,Marstons Mills,MA Property Address: George Valliere Owner: April 2, 1998 Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yeses No Pumping information was provided by the owner, occupant, or Board of Health. _ 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. As built plans have been obtained and examined. Note if they are not available with N/A. al/ _ The facility or dwelling was inspected for signs of sewage back-up. �[/. _ The system does not receive non-sanitary or industrial waste flow. _3[ _ 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: _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. Y _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)) (rwis.d 04/15/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 72 River Ridge Drive,Marston Mills,MA Owner: George Valliere Date of Inspection: April 2, 1998 RESIDENTIAL: FLOW CONDITIONS Design flow: 330 e•p.d./bedroom for S.A.S. Number of bedrooms: Number of current residents: Garbage grinder (yes or no): No Laundry connected to system (yes or no): YE 5 Seasonal use (yes or no): 1V0 Water meter readings, if available (last two(2) year usage (gpd): 9 7= 9U 000 gam)/o H s qG = 877 9 G//�N s Sump Pump (yes or no): /VO -� Last date of occupancy: 1)C- up i e c/ COMMERCIAUINDUSTRIAL: Type of establishment: Design flow: gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or-no)_ Non-sanitary waste discharged to the Title S system: (yes or no) Water meter readings, if available: _ Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and sour a of information: T f�un�Oc t/ y �S g� ocr ih /�o✓r [ fc / rcct� ls-ta-�- System pumped as part of inspection. (yes or no)ND If yes, volume pumped: gallons Reason for pumping: TYPE gFSYSTEM _� 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) VA Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) IVO (rwi••d 0 !15!971 " SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 72 River Ridge Drive,Marstons Mills,MA Owner: George Valliere Date of Inspection: April 2, 1998 BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction: _cast iron_40 PVC_other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANII (locate on site plan) Depth below grade: I Material of construction: ✓concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance —(Yes/No) Dimensions:_ S X 9 a Sludge depth: // Distance from top of sludge to bottom of outlet tee or baffle:�_�J Scum thickness:-TV,- I c%y cr. Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: Pr-o b e 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.) Co,, lit-« -;0/-,� nU Jt y- VL ` ✓t o _< r./ c—4ti t— I cx�ci w,o /c✓ 7a.i.��/ u r W w S yC 1 ) f 4- rn . v��i �N , S ✓YI r GREASE TRAP: /V (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: (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.) (r.vfa.d 04/25/97) o SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: .72 River Ridge Drive,Marstons Mills,MA Owner: George Valliere Date of Inspection:April 2, 1998 TIGHT OR HOLDING TANK:/11 (Tank must be pumped prior to,*or at time, of inspection) (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene --other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Alarm in working order Yes; No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: el.)c / Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) J�^ e :j cA , h 011, , I 4 0 1—at c.r / PUMP CHAMBER:­L/A (locate on site plan) Pumps in working order: (Yes or No) Alamo in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) Ir* lI­d 04/25/971 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 72 River Ridge Drive,Marston Mills,MA Owner: George Valliere Date of Inspection:April 2, 1998 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number. O vi c G X 6 w', as�Zj H L leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: ' Alternative system: Name of Technology: Comments: (note condition_ of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) c� s Ord f l . CESSPOOLS: .4 llq (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: *119 (locate on site plan) Materials of construction: Depth of solids: Dimensions: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) tr—i—d 04/25/97) u P.4• ! of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 72 River Ridge Drive,Marston Mills,MA Owner: George Valliere Date of Inspection: April 2, 1998 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (locate where public water supply comes into house) I I i I � I— OK"uC- wky 1'7 l000��.!!�� (revised 04/25/97) Paq• 9 of 20 A 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM'INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 72 e'er Ridge Drive,Marstons Mills,MA Owner: George Valliere Date of Inspection: April 2, 1998 Depth to Groundwater Feet adjusted high groundwater level Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) V/Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. Must be completed) HOw /OEu �cl� dh ��� � GroUh.4 fN 4-t, F Vi -S aC c �0 6 c. , r �+/��-, o c- /8. f Xd YL v p � h 9 rw . 6711, I t_c%- c �..-� h q �s 9. `f �l n.cj, i s v,0 74 'n y h q r v (r.vis.d 04/25/97) ASSESSORS MAP NO- �7-7CJ q�r -7 ✓ PARCEL N0: C� No....!..`.... 1..5 Fps. l.�.........' THE COMMONWEALTH OF MASSACHUSETTS AMOVED BOARD OF HEALTH Z TOWN OF BARNSTABLE ��t�t1tPFltt �Ur ` t��It1�3M� itr�t.� �1��t,���lYP�tiiri �Prllitt i Application is hereby made for a Permit to Construct ( ) or Repair ( -an Individual Sewage Disposal System Rk(_rV_, Z�) I Lo Location-1\ r s or Lot No. {� _t-. � ------------��-------------------'-��cam----•--- - =- --------...------- Owner Addres a .....D4�..... --- ------------------------ _.. Installer Aess Type of Building Y Size Lot............................Sq. feet Dwelling— No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures ------------------------------- - - W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity------------gallons Length................ Width................ Diameter_............. Depth................ x Disposal Trench— No. .................... Width-------------------- Total Length-------------------- Total leaching area....................sq. ft. Seepage Pit No...................... Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by---------- ............................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ R+' •-••--------------------------•------•--------•------••---------------•-----•----------------------•--- --------------------- •............... ....... "......... 0 Description of Soil........................................................................................................................................................................ V ................................. --•-------....-----------•--------•---•-----••---•-------------- __ _- .. W i_s),r, --------------------------------------------------------------------------------------------------- -------------- ----------------------------------------------- -- UNature of e r or Al erations nswer whe plica le_ r4Li �. ----- -- -------------------- ......... .. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State En 'ronme tal Code—The undersigned further agrees not to place the system in operation until a Certificate of Co ce Ms be n ued b I t board of health. _ r! Sign � 7 �� Dace Application Approved By ............ ------- --- Application Disapproved for the following reasons: ............................. ................................. --................... ......... ................................................y........ ................ . ........................... ...... ....... ---------------------------------------- DatePermit No. / d......... �,, v` Issued ......................... ...... ................................. ...... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH /SOWN OF BARNSTABLE Applindtott for Diti-Vn!3ttl Works Toustrnrtinn rami# Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: ......... ......K.........................1.�._....r s-.................-- �----_S.: .----------------------------._..____..•._.... ........ ........................................... Location-i\� �Cor Lot No. V— --- ` 4� Owner Address W T Installer Add ess UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons....______.___________-___-_ Showers ( ) — Cafeteria ( ) QOther fixtures --------------------------------------------------------------------------------------------------------•---------------•---------------------------- W Design Flow............................................gallons per person per day. Total daily flow_..................._.....................gallons. 44 Septic Tank—Liquid capacity........___gallons Length________________ Width---------------- Diameter................ Depth................ x Disposal Trench—No. .................... Width-__--_____--_-_-__• Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No-----------_-------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit_________-.-----__-- Depth to ground water-_.-_._.__.__-__-__-__-- li, Test Pit No. 2................minu� ._..per inch Depth of Test Pit ___......___..... Depth to ground water........................ ------------ ---------------------------------------------•-----------•-------•--------._...........-----------------•-----------------..............---... 0 Description of Soil.......'"'"....................................................................................................................................................... V ............................................. ..................................... --------------------------------------- • \ { - ,.�........-..""—. -......................... --------------- ---------------- - - - - ---,. U Nature of_Repairs or Alterations nswer whe• applica le._7 U6...- ......e.: ... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State En 'ronme tal Code—The undersigned further agrees not to place the system in operation until a Certificate of Co yce 'gas be n sued b t board of health. _ r (� Sign :... J 2 Q Dace Application Approved By ............ ....... ..... .. , ---------------------------------------. 5-7A.!�..=...�.. C/ Date Application Disapproved for the following reasons- ---------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------=---------------- ------------------------------------------------------------------------------------ --------------- ........................................ qC�.` Date Permit No- ---------- ---- ---.....c2.�J Issued Date ------------------------------------ ---------------------------------------— THE COMMONWEALTH OF MASSACHUSE17S BOARD OF HEALTH TOWN OF BARNSTABLE10-I'lertifirate of Complianre �IS IS TO C at the Individual Sewage Disposal System constructed ( ) or Repaired ( v ) --.�E n — --- y r-� /�nlnsralle at ....T;1 -----.....- - �� `.�. - l--i---1 1 ��............- ------------------------------------------------------------------ -----been installed in accordance with the provisions of TITLE of The State Environmental Code as described in the application for Disposal Works Construction Permit No. .......�V-.... ... .—...._. dated _-------------------------------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE .... .- -1j�".. � �' --i - Inspector -�' --- !7 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Permission is hereby granted...... ......... .. .. , \ -------•---•---------------------------....._....---........---.... to Construe ) o epair +/�aCtt ndividua�l SS�ywa isposal System atNo.------ �� -................. -� C_ ------------------------------------------------------- ------------------------ Street as shown on the application for Disposal Works Construction Per .............. mit No...._, .^_275 Dated...<-.-��/..:c�.,�---....__ Board of Health DATE ------------- y. ;/(jJ FORM 36508 HOBBS 6 WARREN.INC.,PUBLISHERS LOCATION SEWAGE # "1 VILLAGE M ASSESSOR'S MAP 6z LOT07gf ,,01 I. I INSTALLER'S NAME fm PHONE NO. �`\ SEPTIC TANK CAPACITY 1 LEACHING FACILITY:(type) e_%cm , Pq- (size) r� NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER E BUILDER OR OWNER \�YU DATE PERMIT ISSUED: 'r-olsic-1A DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No "�/�( / ' <J it • ` l z 1 V I e 3 a 5� ASSESSOR'S MAP NO v' '7` PARCEL L. 0- CATJ.O SEWA G E PERMIT NO. VILLAGE a. INSTA LLER'S NAME A ADDRESS d U I L D E R OR OWNER DATE PERMIT ISSUED RAT E COMPLIANCE ISSUED__T n� II �y �� � i �� �I �� , � ��.. � a 4 •. �IDT �_�, Fps....: .........._. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .} ................OF .....------....._.............-- Appliration for Disposal Works Tonstrnr#Uan ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Syst.R at -Locatio Addr or Lot No. �/ Owner Addr Installer Address 9Q VType of Building Size Lot.1----'5, ..Sq. feet ,-4 Dwelling—No. of Bedrooms..__...................................Expansion Attic Garbage Grinder ( � aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) C4Other fixtures -------------------------------------------------------------- W Design Flow....... J.........................gallons per person $er dgy. Total daily f�pw_.._..�4.. ........-.............. lons fr 04 Septic Tank—Liquid capacit .gallons LengthS'-'��-_- Width.,4_:�,C�__ Diameter-............... Depth-S_.. Disposal Trench—No. .................... Width.....T.............. Total Length.................... Total leaching area.....................sq. ft. Seepage Pit No....... ............ Diameter.__...X0._..... Depth below inlet...`?' ._. Total leaching area.Z.�...sq. ft. Z Other Distribution box ( Dosi�g tank (� �� i �� Percolation Test Result.�j Performed by.- ,2t ._____ :.. :�_____________ Date....____..............._..__..^__._... Test Pit No. L.4-`'......minutes per inch Depth of Test Pit...k�Q..... Depth to ground Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a -------------------------------------------------------------------------------------------•---....., . ---...---- -------------- De ption of Soil..©` 2 S 1 C� c� 9`4. ��.. � ZJ ��--t 4E-1:�-_...-•--•-. W --------------------------------------------------------------------------------------------------•------------------------------------------------..........------.......---------------------•---•--- VNature 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 iITLL 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in o er io nt ertificate of Compliance has bee issued by the boa of healt •y (� Signed........ D e/ ApplicationApproved By-----.------------------•----- -------•-------...- ......................................... ......... . ...Date Date Application Disapproved for the following reasons:------•----------•--•--•-•--------------------------•--•--......--------------------------...--------........-- ---------------------•--•----•---•••-----------......--------•-•-•--------•-------------•--------------...---•-•--------.....--------------...---•---------------------------------------•---•---•-•••... Date Permit No.- ...................... -25•••-•......•---- Issued........... _ `�-.. � •..... Date ,�AA , N .� ...... �3 'L I 7--Z F$s-. ......_ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...................... OF.... ............................0.\,j L Applirtt#ion for Disposal Works Tonstrwtinn Permit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: n a� or Lot No ,ram Location- ddre --......_ �'` ir:2. -� 5 Z ................ .e! 'ci, .�;°". _ e:........._............._........ a .............. E` * nee d ............... �.. � f`s a:-.._.. .................... .......... M Installer Address r� Q7i C.j �' �1 Type of Building _, Size Lot..�....!.. .::..........Sq. feet U Dwelling—No. of Bedrooms.....:................:....................Expansion Attic (�j�lr), Garbage Grinder Other—T e of Building No. of persons............................ Showers a YP g ...................•-------- P ( ) — Cafeteria ( ) Otherfixtures ----------------•-•--------•-----------•---•------•---•----••--•-----------------•----•------------ -- g > P P ....................•............. Design Flow.___.....:._`?............................ Mons per person per day. Total daily.flow........2..............................__gallons.e, Septic Tank—Liquid capacit}a�.J., _Igallons Length.�'� ._ Width_' .:1 C). Diameter...:.--....... Depth..!...Y-�.. x Disposal Trench—No..................... Width.................... Total Length---- _.-._....f. Total leaching area... ............sq. ft. Seepage Pit No............................ Diameter......0 .......... Depth below inlet---j.:.......... Total leaching area... :.:%..`...sq. ft. Z Other Distribution box C/o, Dosing.tank ( � I, _ t r �7 Percolation Test Results Performed by.. 7/ :�__:�.'-._�._"}:...w`�.�-:...kk.{..::............ Date._..c'._n..C::'................ �l �k C ' t.r �% Test Pit No. 1... ...._.....minutes per inch Depth of Test Pit..... .:: .... Depth to ground water-._:::�.........:..... ' Z, G4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ D Description of Soil.. `�. .``...._.:t. :.`. .....` ! ? t c ..-Q, •?=4,..... -- 1.27-- -1 1 --- 3......................................... ..................•---•--•---_._..-----•-----.........---.....-----•------••-----•------.... ..............--•--••----•----•--•------------...... W UNature of Repairs or Alterations—Answer when applicable............................................................................................... .................................................................••-----.....--•----•----------..........----........---•------------•-....................---...............----....------............. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLI+, 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in op ra •o nti a C rtificate of Compliance has beel issued by the bo.a.r o heath ........Signed..... � .... ..... . • . :.._Da .... Application Approved BY....... ......... .. ---. ....... - 2 . = _ I..._. Date Application Disapproved for the following reasons:........................................................................................................... --.....--•--....-•--•........................•-------...-----•----•----•-•---•-•---•--............------•.•------•--•-.......-•--•----..._--•--•---.......---------••-.............._......---•........_ Date Permit No.. ................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �2 eNf........OF......... ...................... Tatif irtttle of faomplittnrr THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed ( or Repaired ( ) by....... .............................. --•----•---•--................---........................ .........._........_. ..._ .._ Installer _ / ... ......... TITLE 5 of The State S has been installed in accordance with the provisions of anitary Cq de ap described the ............... dated "�/--2..` . C3 - application for Disposal Works Construction Permit No.... ,. _. . ...... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........................ V..-- .: S..� .............. ....... - Inspector..................... ............................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH • �� { Z >.............. .. ..........OF..... ....................-...............-......._................... .---••--•---�77 No......................... Fn..... . Disposal Works T - ns#rur7s ;�' Permit Permission is reb anted.......... �'��'`�� 'S to Construct ( or R�air� ) an Individual Sewage Disposal S atNo...................... ._..---- ............. Street �- as shown on the application for Disposal Works Construction r t No...... �...��. at&d......7.2'1 .. v ........... �12�� . -e.........._ r Board of Health DATE. r - .... ....................••---•----......•--....... FORM 1255 A. M. SULKIN, INC., BOSTON =:i:i -t•-' : : -- - 77 o / I /a / 2 . 3 o / _:__+,_;-+..- ... .. . .. .. \ � ,0 �• •""'ems.. :.�..�._ _ ........_. _ ... ....�. : .... . . . . . 0 .; Zo loc+ 10, OF Mks i PETER SULLIVAN j No. 29733 f o ... INC D►4, , Y F SI:pTIG TAIJK� �3pX rho �445 G.P, A. (9"\L• -rAr`r lL t ` / r ..'51 t:)eV4 LL4V 178 -s F r�. RICHARD :. x�CR w.+, 79 1~:::.x: .:1 O774 R D• LILY PLOW = 330 Ca, V.,D - - � • 7 ; tE w P1ST. -Qv � //t/ �vo o ►. INV 7 G�,1^• I INu 4 D ^��-v. - . - W4,TO Y-0 PLO ____..__. ...:. ..._ . _... 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