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HomeMy WebLinkAbout0481 RIVER ROAD - Health 481..River Road Marstons Mills P A ='060 014007 I I V SEWAGE INSPECTIONS LOCATION 481 Rivet Road DATE 1013103 VILLAGE t7a2,3.tonz lrliU.6, Ma_3_s. ASSESSOR'S MAP & LOT -INSPECTOR ao.6eph P. (�acompke2 aa. SEPTIC TANK CAPACITY 1500 ga_Uon6 LEACHING FACILITY: (type)Z-Ll_1000',6 4500 gaiion.e (size) NO.OF BEDROOMS 4 ,BUILDER OR OWNER i3e znea e s a2anay OWNER MAILING ADDRESS Same P \ ^\9 'ool o r L��J TOWN OF BARNSTABLE LOCATION �=L�/ % rue g, r_i.) SEWAGE # S®f VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. 7 �f il0'7-37 � SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) _ -%o cw G-�c NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER '+ >r BUILDER OR OWNER y s 6'M % -cc D DATE PERMIT ISSUED: I�oy/96 DATE COMPLIANCE ISSUED: o VARIANCE GRANTED: Yes No i i (VI n a ` � � d U�Y No........ 9......�E3 THE COMMONWEALTH OF MASSACHUSETTS of Me BOAR® OF HEALTH .............OF............. . .---........---...--------- , rlirtttiun for sttl Workii Tuurr#iun Prrutit 5 " f r% QF �N ton is hereV made for ermit Construct ( ) or Repair ( ) an Individual Sewage Disposal .. .... /,f,.Z Location.Address or Lot No. 07 .__.-... - - --- •---• •---•-•---•-•-------•- y'� Owner Address ... .i.X�.€._.7 :.1.J.-.L.----�1!14 �S1 F+L-.... �..... Installer Address UType of Building Size Lot.... 1 -----Sq. feet Dwelling—No. of Bedrooms............. Ko -___-_---Expansion Attic ( ) Garbage Grinder ( ) P64Other—T e of Buildin ...__..... of persons............................ Showers — Cafeteria Q' Other fixtures .. ...... _ allons per person per day. Total daily flow.................�.a............_._ lon W Design Flow............... - --g P P P Y• Y ------ l� �• WSeptic Tank—Liquid capacit _ '-_--gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—. 0. ..........•......__. Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No------ ....... Diameter....... Q.T1.. Depth below inlet....C.�-..... Total leaching area.Aq.7...... Z Other Distribution box ( Dosing-tank ( ) '-' Percolation Test Results Performed by._ . . _�` .�L5.4 f .�t_rRlV _ ....... Date.......$7/_ P/!.7 ....... aA Test Pit.No. 1.____.�__--minutes per inch Depth of Test Pit....... . ..... Depth to ground water.....49........... G%,04 �� V Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ � --------------------•----..-- ----------.----- 0 Description of Soil........I ---.���.P ...-..r_tr. U ---.....•••••-•-••---•-•---•------•-----•••-•--•......-••-•---••--••-•-•-•--•••-••-••...................•-•-•-•-......•. W ••••-•-•••----. ...............................................................................................-DESIGNING-ENC4NEER.M.0 T.SUPEi' .... U Nature of Repairs or Alterations—Answer when applicable.__..___ INSTALLATION--AND_-OERTI L' fN WR1TIiVG--..... •--------------------------------•--•-----------•------•--------------•----•--------............--------•---•--'��tE &�fSTEAII-1NAS..IN...... =D 11V S'�RtO�F i Vim' . Agreement: ACCORDANCE TO PLAN• S 0 A`5 tc&at P�t The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with Vrrt,4� the provisions of TIT 1L 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beenss/ued by the board of health. Si --------------"-� `---------------------------• to Application Approved By................ )..(1. .. - 2_. � ..._._�c7 .!a..I...... ---•---------------------•- -Date Application Disapproved for the following reasons:................................................................................................................ C1 Date L Permit No......................................................... Issued............ -• � D{��� G+� --- --' . ��� - � -------•------- ` p "40/. `f. No.. - - _ FEs.............................. THE COMMONWEALTH OF MASSACHUSETTS �t F �qq BOARD O HEALTH o�� q - .. .-.......oF.................. 3f Y ppliration for Disposal Works Tonstrur#ion Prrmit �O on is herb ma for a Permit to Construct or Repair an Individual Sewage Disposal Gl TER � Y- - � ( ) P // ��( ) g P FsS '1�.-..........-... !!/ .- ! `........................................ ......... �%1L/. �� ` - -... t--4'4-•�-• - Location-Address or Lot No. Owner�; Address � � InstallerJAddressJi ......_"-•-•-"�'�s UType of Building Size Lot_____ / ......Sq. feet Dwelling No. of Bedrooms..............3.........................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of ersons____________________________ Showers a —Type g ...................•----•-•- P (--->--- Cafeteria ( ) Otherfixtures ------------------------------------------------------------•-----------------•------------------------------- ----------- W Design Flow................ ......__.._._......gallons per person per day. Total daily flow.................3. 4 ...............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._.__. 4�' .. Depth below inlet___.a�.__"�_a_....__ Total leaching area _____! Z Other Distribution box ( A-)- Dosing tank ( ) �!� `-' Percolation Test Results Performed by. �'-�__ S- . e✓�_ .t ��a__�__.____. Date_____ a (� Test Pit No. 1_____.�.....minutes per inch Depth of Test Pit......Z.5.__... Depth to ground water____l_��.________-_- (i, ba Test Pit No. 2................minutes per inch Depth of Test Pit.. _____._.________ Depth to ground water........................ Description of Soil.. d`:%1 ` 0� y`' 'r �'' 9! f4 ...mac /7��?r ? U -•---•----•.........................................•----••----•----•------------•-------•-••---•-------•---•---------------•--•-----------•---------------------------•-------------------------•----- W UNature of Repairs or Alterations—Answer when applicable............................................................................................... Agreement: 10 S(;1 The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TI:'I`�(�� 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certii sate of Compliance has been issued by the board of health. `�4 e-Signd l ................................ `- �� j- -- ApplicationApproved By•-----•-•------•••-----•t-----ter............................................................... } ..... ............... Date Application Disapproved for the following reasons:----------•----•----------------------------------------------------------------------------------------------•- Date Permit No......................................................... Issued '. ....� __ _ : .. DLte i THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .4 OF........ ..................... Tntifiratr of Tomplianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by......................... --�.•••------.......--•--._..._T---..._......_....• . j --7 (_ �r f � � Installer at -*-�--.---- •------------/--•------i-+•�--------�--------------------..y._...-------------------------------------------------------------------•---------...------------- has been installed in accordance with the provisions of '!'-!"'7�; 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No...... '_;_____''_:_ _ dated_.-- ,.. ... cl_`I_..________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUN TION S, TIeSFACTORY. DATE.............. t � ....../.. _..._... Ins ecto ...... P THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -�......... � �.�' �.'T'" ,,�c.!f N�t K•'-fit_ .... ....... .. No........................... FEE.__..f�: Disposal Works TOnstrudion rruti# Permission is hereby granted �. .-. ........ �_lf =� �j tl' -----------------------•-------•--...------...----------....---._.. to Construct ( ) or Repair ( ) an n I ividual Sewage Disposal System ' t.... =• -------------- Street c , as shown on the application for Disposal Works Construction Permit No------3_f_!1_-_-�i___ rated____r_?I_ �- i---------------- _ ..................................... L) Board of Health DATE....... - --`I.__ .. FORM 1255 HOBBS & WARREN. INC., PUBLISHERS Completed by HIGH GROUND-WATER LEVEL COMPUTATION Site Location: '� �� �_ Lot No. Owner: --�L LLE6,44171 Address: p?,!5, (��.� 687 10ASHPCC. 1k1A c;z6l Contractor: Address: Notes: STEP 1 Measure depth to water table to nearest 1/10 ft. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -5/zo/6 �4 date STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: ' SDw-L53 A) Appropriate index well B) Water-level range zone . . . . . . . . . . . . STEP 3 Using monthly report"Curren t Water Resources Condit.ions" determine current depth to water level for index well . . . . . . $ /B mo yr STEP A Using Table of Water-level Adiustments for index well STEP 2A , current d&pth to water level for index well (STEP 3) , and water-level zone (STEP 213) determine water-level adjustment . . .. . . . . . . . . . . . . STEP_ 5 Estinate depth ,to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water �Z9 level at site (STEP 1) . . . . . . . . .. .. .. . ..... . . . . . . c � y17 � TOWN OF BARNSTABLE OFFICE OF t 31AH39TLBL BOARD OF HEALTH NAM � i639• \�0 367 MAIN STREET 'ED MpY HYANNIS,MASS.02601 / k• January 31, 1990 TO: Alfred Martin Building Inspector FROM: Thomas McKean Health Agent RE: Lot 7, River Road Marstons Mills, MA A building permit and sewage disposal permit for property at Lot 7 River Road, Marstons Mills, owned by Timothy Leedham was approved for a three (3) bedroom dwelling on October 3, 1989. This floor plan shows three (3) bedrooms, one (1) family room, and one room above the garage. Now, the Disposal Works Installer, Robert Berilacqua, states there are five (5) bedrooms under construction, according to his "As Built" card. This dwelling was never approved for five (5) bedrooms because it is located in a ground protection district. Please do not issue the occupancy permit or allow any additional construction except for the approved three (3) bedroom dwelling,annd clearance from the Board of Health. Your cooperation in this matter is essential in protecting our public supply wells. V er truly yours, J Thomas A. McKean Director of Public Health Town of Barnstable copy: Chairman Board of Selectman Timothy Leedhan enclosure �►!V er,T'y '1 � �4 '�1�' v1�#• },'�/'II.. L i a, L7� t'&sF•t*^� �w,✓.. __'-__'_ ._ .._-__... _-_.__ __. i 6bj 14 �. .. t �.o i ------}•--1 i ! r , � '� � _'r"- �r�• I 1 ref t• z,. 1+.u.� _ - - o*--j. f vFo,RI •1•, J �- ----�. .� �-♦ t: ., -y , ,ate! Q��{j� I ? I + � _G�(•a• {G. ? ^ J>. - I'TetaF�-1 n N' I � ��I�� -Y �L7.� 1 ��' � f r}• \N" Kef_�.��I j '{ �.a ,1 IT, 14 tks j 1 � ..---- - -!?'•Q...-.- --... ,� .. .. il•�0._ _........ l$,� _.�7c'�It' _.. '�: '�•2 ... " i'�l't � 1 - - _... _.4t to Ott+' MI '�T1'.✓!1J `S �'f' I' t W PI I I c,��z-fro�_ •�.+ . ._L � __l�' __ '� _ _ � �" � i t La I c. v 1 •J 1-4 'd cr Of .� ., YAROSH ASSOCIATES, INC. al MMiKI'f tlTdll+fff '.h. i .. �.,•a,r. � _ AEMiO(E PLnN;A:•:r Nr)'18G '� r.'4♦''n1'I 3 L ... 11N11Fq ANt C1ie�•urR:aANC:�9 1�' ? '1- '1 wR ,1 WYMI WffKKf/t Tf rr �44 - .,�4 " r .. S4,,=tWw( row°« i v g �JI'"q. -` Sys � y 7, .,�` T . e1.,,p .��� M•d`i F tJi�q,�.. � 3Y'b". '1'` .♦ , °p w�+•fY.p•qr. ��/"-� �,�;.,�• I*�, ol >, % ♦.... -.r-r-�� �' b.l-.i2 I1.�.�"� � _ __ .. . II ,�` � ,���?"^a #�w�ijll��"e• �1' 1 ... 20 TT k zw� cb� I aL it � I �'�� II�R�/FT ,tl'. � ( t � �I� .. + �i-- ' �k,� �� ai., �� ( •�1 ��11 I i N • l 01 - _ I I t � I i;"'-�+..•v� 1... .. .. 5.�f �•w.Kt O,V • I I I i 'I i ;W� 1 7 .r .C41L•GO',r� + . ..: t n �I �h �d%1i' 11 _ JS-Iew }�� s 0.;f�•� i_ n �� ` Iry I 1 y I i1 ��-__ V,'..,,,3.1' !/ ': .-',.��—� yy• _l� r. ..i -- y,�s : �l �I '�i - a1 I !_.-� �•--- ---.1) �f�l, w�Dt �1 _. 1 i �.1..✓.�. . II '• - 1 I � �,v..•q...:.� 1 I I 1 I �. I.w"r� .�...1 1 U �j��_.' .I ��. i ID I n' �_ -- J1 -,c. t—. ^wo^ -; .. ._...... A•d ' * �olvta„cl nu�:uwNl �;�' �•a.!�• -' -. .,r.. ... 7y�P• .. nl • W.Ir....LY ,. lY �h�.1.. ..... :it Y - - 1 > .1,; .. �• �`� � Ir.L., III ... I .•� r•. ). �.�'W ," - - } y. �. " YAROSH ASSOCIATES,INC. j S TFfEEF PLAN MAY NOT BE '1 I''-• 1.� ` •t11EF'HOgUCPIr fIJ:7NULE OR PART _ .,.� -- ARcwttm nA"'•t 1., •�'Kr UNDER ANYCIRGUf/STANGE& lyl r •` �• 1Dw . R;`� - �Z�r • - 1 wl *All:ll. fly .d --- - Perm t N.umber. ' Completed by HIGH GROUND-WATER LEVEL COMPUTATIOt,' Site Locat ion:��_� �� V�� � _ Lot No. Owner: �. L �EQt{tS/YI Address: �6 . So X �� /YIASgpEE� /Ylq oZ61i' Contractor: Address: Notes: STEP I Measure depth to water table to nearest 1/10 ft. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -S/zo/B �4 U date STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: - spw-L53 A) Appropriate index well . . . . . ... . . . . B) Water-level range zone . . . . . . . . . . . . STEP 3 Using monthly report"Current Water Resources Conditions" determine current depth to- water level for index well . . . . . 5 /8 mo yr STEP Using Table of Water-level Adiustments for index well STEP ,2A , current depth to water level . for index well (STEP 3) , and water-]eve] zone (STEP 2B), determine water-level adjustment . . . . STEP 5 Est.inate d"epth ,to high water by subtracting the water 44 level adjustment (STEP 4) from measured depth to water - level at site (STEP 1) . . . , . . , . . _ , . , �'T DATE :7013103----- PROPERTY ADDRESS 481- ---- /2oacl-------- 02648 On the above date, I inspected the septic system-at the above a dr-e-s-sv Tnis system conslsts of the following: RECEIVE® 1. 1- 1500 gai-Oon 3e/2tic tank. 2. 1-Di.3t.,zigut-ion &ox. OCT 2 12003 3. 2- 1000 gaP.Pon /2Aeca.st .Peach.ing /2.itz. Baseo on -my inspection, I certify the following conditions: TOWN HE�ALTBHDEFT. 4. Th.i.a .ih a t.it Pe le.iue he/at.ic zyzeem. (78 Code) 5. The 3e/?t.ic 6yztem .i.s .in /2Ao/2ea woak.ing oAdea at the /2AeZent time. 6. 1-12it .ins dam/2 at the Pottom and 1-/2.it .iz 56" Pe-Pow the .inveAt /1.i/2e. SIGNATUR 7414, Name J P_ -Ma comber_Jr _ _--- ompany : ,�gg��h ��- M�S4mt2�r d_ Son, Inc . xLLL-._ �ja _Q2-632- 0066 ^one : 508 . 775_ ) ) l8 -_ _-_ ___ THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY a I' JOSEPH P. MACOMBER & SON, INC. Tinks-Cesspools-l.eachllelds Pumped � Installed Town Sewer Connections P 0 Box 66 Centerville. MA 02632.0066 275.3338 775.6412 I� COMMONWEALTH OF MASSACHUSETTS (1-4 EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:481 R-ive2 Road a2.6 one c h, a.6.6. Owner's Namef3e2nea.2 Pa/Lana Owner's Address:3 ame Date of Inspection: 1013103 I Name of Inspector: (please print) ao.6e/2/z P. Nacom&ea ;/t. Company Name: J. P. Nacomge2 (t Son Inc. Mailing Address: Box 66 Centeay.i—Rie, Matz, 02632 Telephone Number: 5 08-77 5-3 3 38 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ' ��Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails i Inspector's Signature: f2t Date: 2J —625 The system inspector sha ubmit a copy of this inspection rep rt to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner.shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 r Page 2 of I 1 OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 481 Rivet /toad Mae,31-on.6 l7iPP.s, Matz. Owner: Be2nea2 Pa2anau Date of Inspection: 10/3103 Ins =SystemPasses: ) ry: Cbeck A,B,C,D or E/AL_ WAYS complete all of Section D CA. 4A 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The ZePt.ic 3y,3tem .iz .in Rao/2ea wo2kinq ozde2 at the /22e,6ent time B. System Conditionally Passes: One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. X// 9The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. 'A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INS.PECTION FORM PART A CERTIFICATION(continued) Property Address: 481 Rivet Road Owner: Beanea2 /Oa/tanay Date of Inspection:1 Q/3/03' {.... C. Further Evaluation is Required by the Board of Health: 4)b Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health,safety and the environment: .VD Cesspool or privy is within 50 feet of a surface water U1 Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone f 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 109 feet but 50 eet or more from a private water supply well'•. Method used to determine distance--/ � "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form, 3. Other: 3 Page 4 of I 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ' CERTIFICATION(continued) Property Address: 481 Rive-2 J2oad ja2ztona l7i 2L.s. Nri.3.6, Owner: Be2nea�'ay Date of Inspection: 1013103 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 !/ iquid depth in.ces&peal is less than 6"below invert or available volume is less than ''A.day flow equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped 0. Any portion of the SAS,cesspool or privy is below high ground water elevation. ZAny portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface w supply. ,oater y portion of a cesspool or privy is within a Zone I of a public well. y portion ofa cesspool or privy is within 50 feet of a private water supply well. y portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this forma 4)0 (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303. therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply m system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim W - - _ Y g (. m Wellhead Protection Area 1WPA)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. 4 f page 5ofli OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 481 R-i.velt Road a2.7o73 7,777 , a.5h. Owner.Be2nea l a2anay Date of inspection: 10 3 �... Check if the following have been done. You must indicate yes"or"no"as to each of the following Yes No umping information was provided by the owner,occupant, or Board of Health /Were any of the system components pumped out in the previous two weeks —Z _ Has the system received normal (lows in the previous two week period ? Have large volumes of water been introduced to the system recently or as pan of this inspection ? Wcre 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 ? t/ _ 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 ? p The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes no/ J Existing information. For example, a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CMR 15.302(3)(b)) 5 Page 6 of I I OFFICI kL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 481 R ve2 Road 726 on.3 7 , a�A. Owoer: l3eznea l a zanay Date of Inspection: 73103 RESIDENTIALFLOW CONDITIONS ,. . Number or bedrooms(design): y Number of bedrooms(actual): DESIGN now based on 310 C�M��RJ�15.203 (for example: 110 gpd x M o(bedrooms): Number of current residents:uwa- Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yye}} or no): (iryes separate inspection required) Laundry system inspected es or no): 1CL Seasonal use: (yes or no): Z Water meter readings, if available (last 2 years usage(gpd))2001=1 19 000 yai—pon,=326. 03 qPD Sump pump(yes or no):NO 2002=95ga.P.eons=260. 28 qPD Last date of occupancy: COMMERCIALANDUSTRIAL Type of esublishment: <j.4 Design now(based on 310 CMR 15.203): _gpd Basis o(dcsign now(scau/persons/sgft,etc.): Grease trap present(yes or no):&0 Indusrrial waste holding Lank present (yes or no);,4 Non-sanitary waste discharged to the Title 5 systc (yes or no):/IJ/F Water meter readings, if available: ) Last date 6(occupancylust: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as pan of the inspection(yes or no):yo < I(yes, volume pumped: 0 gallons •• How was quantity pumped determined? IC44 Rcason for pumping: TYPE OF SYSTEM t�Scptic tank, distribution box, soil absorption system 4)Z) Single cesspool a'P Overflow cesspool ,VD Privy Shared system(yes or no)(if yes, attach previous Inspection records, if any) 4& InnovativdAllcmative technology.Attach a copy of the current operation and maintenance contract (to be obtained 6'om system owner) r1 0 Tight tank �Anacb a copy of the DEP approval �O Other(describe): llc� Appro 'mate zee of all components,date installed(if known) and source of information: Were sewage odors detected when arriving at the site(yes or no): 6 i Page 7 of I I OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 481 /2ive2 /Road a2,3 on6 Owner:Be2nea l a/zahay Date of inspection: BUILDING SEWER(locate on site plan) Depth below grade: 15 / Materials of consrruction:,V0 cast iron i/40 PVC.Vc)other(explain): .V,4 Distance from private water supply well or suction line: /d X- Comments (on condition of joints, venting, evidence of leakage, etc.): ao.inth appeal tight. No evidence o,yeeakage. The .6gtem .i's vent6D 711ROU911 711E R007 VEN7S. SEPTIC TANK: 20ocate on site plan) be21944"e X Depth below grade: Material of construction: /concrete &metal.-60 fiberglass,00polyethylene /qL other(explain) ,UA If tank is.metal list age:AJ6 Is age confirmed by a Certificate of Compliance(yes or no):d�(attach a copy of certificate) Dimensions: /0,4°Jfr tr'/�"�4 itry'�/ Sludge depth. Distance from top` f sludge to bottom of outlet tee or baffle:/ �� Scum thickness:� .,.e Distance from top of scum to top of outlet tee or baffle: Distance from bosom of scion to bottom of outlet tee or bpflle: How were dimensions determined: /+ agr Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid evels as related to outlet invert, evidence of leakage,etc.): Pump .the -sepzLie tank eveay 2-3 yeaaz. Zniet 9 outie.t tees a e Ln p ace. e tank .l..b 3tauctuAatty 1ound an .a owz no ev.idl nee o .lea aye:L.iqut'd .Reve.e out Qet .inveat .iz 51" GREASE TRAP/1"ocate on site plan,) Depth below grade: ,� Material of construction:4j concrete/2/lm eta I, fiberglasL,J�polyethylene-tAther (explain): Dirnensions: Scum thickness: Tly Distance from top of scum to top of outlet tee or baffle: 410 Distance from bottom of scum to bottom of outlet tee or baffle: eif Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): �17 on A Vann ;A nnf PaoAon t Page 8 of 1 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:481 R2ive2 Road raa.6t on.s l'l i PO.s�lrlazz. Owner: [3enneaZ a/tanay Date of Inspection: TIGHT or HOLDING TANKA�/ tartk must be pumped at time of inspect ion)(locate on site plan) Depth below grade: _21 Material of construction: � IA concreteAmetal VA_A polyethylene AIA other(explain): Dimensions: Capacity: A24 _gallons Design Flow: A4 gallons/day Alarm present(yes or no):_A4 Alarm level: _ (,�� Alarm in working order(yes or no): Al# Date of last pumping: Comments(condition of alarm and float switches, etc.): 7iy o z ho.Pcl-rzq an .s a2e no p/Lezen.t DISTRIBUTION BOX: Z/ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Di,6t�c-.gut on Sox ha,3 .two .Pate2a-ez. No evidence ol Zoiid,6 ca1t1z oho O akagep in o OA Ou- OL .the Sox PUMP CHAMBEW-f—"locate on site plan) Pumps in working order(yes or no): A)0 Alarms in working order(yes or no):- Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): puma Chang ,6 noi ?,ZpAr f 8 Page 9 of I 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:481 /2-.ve2 Road aazs onh .c e, a.6.a. Owner: Beanea2 Paaanay Date of Inspection: 1013103 L7" SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) 2— 1000 ya2.Pon /Zaeea,3t -teaching pitz. If SAS not located explain why: Located: See Page 10 Tye/leaching pits, number: leaching chambers, number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dime>�ons: C /�overflow cesspool, number: D innovative/alternative system Type/name of technology: ale /4, Pe 67o'64� Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): Loamy nand to medium tine nand. No zigne oZ hydaauiic /aieuae oa rzondina. Soi. z ate dar/. ece a .con' .c-.3 nonoamu —/?.c .ch am/? e othea ha,3 waste watea. 16' ge.tow the -.nveat /?.i/?e. CESSPOOLS1ZVe(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: O Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: �/Q Indication of groundwater inflow(yes or no) Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Same a,6 a&ove PRIVYAIA 1(locate on site plan) Materials of construction: Dimensions: '04 Depth of solids: 4�lw Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): P/7 1 uu 16 noY- ./?ae lent. 9 Page 10 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 481 Rivet Road 72,3 one 7 ,6, i azz. Owner:Be2nea P Pa2ana y Date of Inspection: 1013103 r` 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. rA 01 >; l a 10 L Page I I of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ., SYSTEM INFORMATION (continued) Property Address: 481 12.ivelz /toad /Ita2,6 onz Owner: z3e/LneCLi l a2Enay Date of Inspection: 1013103 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate (check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record • If checked,date of design plan reviewed: NA Observed site(abutting property/observation hole within 150 feet of SAS) N(L Checked with local Board of Health-explain: NA yLS Checked with local excavators, installers-(attach documentation) qZs Accessed USGS database-explain: tad Qe, NA. /is. You must describe how you established the high ground water elevation: 1-L,6ed: gahze�U X 11.itee2 (oche. 12176194 G2ound wa.te2 eievations agove sea QeveP. deed: UNS. 09,3eltvat ion weii data ,tune 1992 Cleed: dSgS: 7echn�cai Bu22etin 92 000 1 / .Pate #2 Rnnua—P aangee o,o gaound watej. ePevatione. Leaching Pit :cct Groundwater: Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method Therefore, the vertical separation distance between the bon . Of the leaching pit and the adjusted groundwater table is � ��`� feet. I1 1)1 3FQSAU SYSTEM I NJPKCTION FOPM PART CEkTf V!CATH -TVPI OR FRIHT CLEARLY- PhOPERTY iNSPECTED ;TRH ET WHO 487 Riue4 Road nagAjoaj Ali& Nato, ASSESSORS MAP , 6LOCK W PARCEL .......... OWNER4 NAME Beaneai Pananay ----------------- NAWF OF it ................ .......... CKPANY NAHE JAWK20jr. COAPANY TELEPHONO 1 506 I 77§ 3338 FAX HI ) 790 thnt 1 Ove garsonally inspectcd the gow6ge A 1UPOST! his address W HaL M infOrmation reported is tvuu , 6ccurate , ani "W " Of Uf the t0l • The inspecLion was parfgpmed ,d tons rawding upevndo mobternnce , ond r9pul ? arc congj ; LthL with my tvninkg and experience in the propQv functj ,n ,d , I ,t ...... . . ... site Z0,10 djapC351 vynkms . The inspection which 1 h0vo conducted hut not founj which indicacas thst LhQ sy, t,, f, 11 , to adequately prutyct P U 1 ic Von " OP thy envircnOW B4 defined in 310 CMR 15 , 303 , Any FailaN2 criLcHa not evalunted are ns stnted in the FAILURE CPHYPIA voction L f c The "Ps" Or which I hAve CoNdOctod hns found thst the sy5tQm rg1j , pnotecL too KnVic hen! th and the QnvirormW In 6ccQrdBnve 5 DO ca 15 , ?Y3 , g7a winh CRITERIA of th! s 1 PART 2 Orm ficnLiOn most providod to CUU1 , ) Und Lhe DUANU Or nZALTN , MH 7 if the inspecLian FAIL " Khin one Ye' r or FA IdLoKDc�e "hf m thoe in uvOue h l � pe bator un ,PvIvidud in 09 Cm: • t .) ,per �\' 'SE'T'TS COMMONWEALTH OF MASSACHL MCUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF FNVMNMENTAL PROTECTION 0 WLWTER STREET,BOSTON CIA 02108 (617) 292-5500 TRUDY CORE Sete" DAVID B.STRUM ARGEO PAUL CELLUCCI Ca®miahaasr GoverwT suSS1MFACE SEWAGE DISPOSAL SVSTf t 11SPECUON faOflM IPART A R r vcR. wine of Owner Proper"aadra�- `� as at owner: cam of inspecdoi: Name of impost--(Ples"woo 10,ft-*s r- 1 am a DolpPr�system inspector p"na'od�O Section 15.340 ai INS S p10 CMR 15.0001 Cary N.p»: , 1 r�►.?�► l tss v a.,t 3 G ;111 fYlairg Addrassc :�s► a a G .� �Q Tdeplss>s s Nrrrrrber. ..mr+er ?10N STATBYIB r system at des address and that*a information reported below is true, accurate 1 tog,"that I have personany inspected the sewage rformed used on my training and experience in dw prepe'function and and complete as of the firm of inspection. The impaction maintenance of on-site sewage disposal systems- The systems Panes _ Condl6onally Passes _ Needs Furgm fcv**don fly Vw local Approving AudmdW . Fads . Dam irspectrols Signsewc ' ` t dais inspealon report to the Approving Authority(Board of 1448M or OEPfwishin thirty 1301 days of The System Inspector shall submit a copy of yam is a shared systa�.or pas a design flow of 10.000 gpd or graatw. and ths�°rn ownO to the shell submit ON r tm�regional oMka of 1M OepeKns �' system owner and copies sett to the buyer.N applicable,and da approving sudw ft- MENTS .��'S�C rt is c P c`R ri- .,�� /�--s' ,� NOTES AND COMMENTS 1- e a��r r lo<G �� �m � $'U c• X C'�CCC/v C 0 no P�•' 6,'—S r o V :a N E o UZ Page 1 of 11 revised 9/2/98 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION loondw 4l Property Address: Owner. oats of Inspection: NSPECi10N SUMMARY: am&98, C, of & A_ SYSTM PASSES: _,�1 have not fond any kdormstion which hrdcatsa that any of the f8il we conditions described in 310 CUR 1 S.303 exist. Any failure criteria not evaluated are indicated below. COMVAE -. B. SYSTBA CONDIigNALLY PASSES: One or more system ewnponerrcr as d"ca"in the'Cetdtional Pails'section need to be replaced or rapsked. The system.upon cornplation of the replacemnem or repair.as approved by the Board of Health.will pass. Indcate yes.no.or not determined(Y. N.or NO). Describe basis of determination in all instances. If'nat determined",explain why not. The septic tank is metal.unless the owner or operator has pro4ded the system inspector with a copy of a Certificate of CowOw ce(attached)indicating that to tank was Installed within twenty(201 years prior to the date of the inspection; or the septic tank.whetter or not metal.is cracked.structurally unsound.shows substantial Infiltration a exfiltration.or tank failure is imminent. The system will pass Inspection if the exisft septic tank is replaced with a complying septic tank as approved by the Board of Hoeft. 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 dstributian box. The system will pass kupection if(wAh approval of the Board of Heahhl. broken pipes)are replaced obstruction is removed distribution box is lekkefied or replaced The system required pumping we than few tiara a Vow due 10 broken or obstructed pipefsl. The system will pass Inspection if(with approval of the Bwd of Hed*L- broken pipelal am replaced obstruction is ento revised 9/2/96 Pap 2of 11 r 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM s9SPECTION FORM PART A f3M g WICAIM Icant romA Property Ad*mw Owner: Oaba of bWPGdMrr- C FURTHER. RTHER EVALUATRON IS RECiUMED BY THE BOARD OF HF1LLT1k Condidans aaiat which Regain further fustian by the Board of Health in order to d*Uwndm it*a system is Ming to protect the pubic ha old t.safety and 10 Owkwan nL 11 SyVW WILL PASS UNJMS BOARD OF HEALTH 06 rERNM N ACCORDANCE VNI N 310 CMR 16-10 IINI 1 TMAT THE SYSTEM 6 NOT SXjCTK*MG 0 A MANNER WHM WtL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE BWIRO WMEP T: `Gaspod or pivll is widt in SO Nat et staface weber wedarrd or a salt ararsh. Casspod er pro is widin SO Net at a borderft wepta� M SYSTEM WILL FA UNLESS T BOARD OF HE LL HE ALTH LAND PUBLIC.WATER SUPPLIER.F ANYI DETERMINES THAT THE SYSTEM 1S F MCT1ONIMG N A MANNER THAT PROTECTS T1E PUBLIC HEALTH AND SAFETY AND THE ENVYRONMBUT: The system hu asepdc tact and sa a syaam(.S/IS1 and the SAS is within 100 teat of a surface water supply of tributaM to n surface water supPy- and the SAS is within a Zone 1 of a public water supply wdl. The system has a sepdo tarok and seer abserpdan�� water apply WON. The stem hes a espde tat and am absarpdon aystr!m and the SAS is less 50 feet of t private The system bas a sapde tart and soil absorption s»>�NOW Ow SAS b lass thta tOO teat but 90 Nat or nvxe from a for eoiform,baeterin and volatse or9aric irrdicatas that t! —' phrata water supply nos,ueless a was waea aalysis of attattanla phro0 m and nibraba dV09M is aqud to or less wen is free from oa■udon From*0 faaft and d» presence leppo�nredon not va6d1. than 5 pprn. Madwd used to dsts, ,-6atance 31 OTHER revised 9/2/98 ftge3dII • Y SUBSURFACE SEWAGE DISPOSAL SYSTEM VUPECTWN FORM FART A CERTIFICATION Iearenuedl Propwty Address: Owner: Deite d D. SYSM FARS: You must indicate either-Yes'or'Na' 10 each of die 1 h fallowing: P haws dete mined drat one or more of the following feiiwe conditions adst as described/�-- in 310 CNIR 15.303. The beats for Ws data inallon is identified below. The Board of Heahh should be concreted to datenine what will be noes to correct the I sary a fa tire. Yes No Backup of sewage into tuft OF s1►atem corrmponard duo In an overloaded or clogged SAS or aaspod. Discharge at pending of effluent 10 the surface of the ground Of surface wa0ers due to an overloaded of dogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or dogged SAS or cesspool. liquid depth in cesspool is less than 6'below Invert or available volume is less den 112 day now. Required pumping more than 4 tines in the last year NOT due to dogged or obstructed pipe(al. Number of times pumped .... _. Any portion of the Sol Absorption System.cesspool or privy is below the high gronrndwarter elevation. Any portion of a Cesspool or privy is wiMnin 100 feet of a surface wale► supply at terry/o a surface warier supply. _ — Any portion of a cesspod or privy is within a Zone 1 of a pubic wall. Any portion of a cesspool or privy is within 50 feet of a privets water supply suer. Any portion of a cesspool Of privy is less4han 100 fiat but gnatar than 5o feet flan a privasa water supply well with no acceptable water quality arnelj ' If the waN has been eW_, to be aogptxndn.aURch oepy of well water analysis for Coderm 11aetaria.velatie organic compounds.ammo.is ribogen and. niaagsrc E LARGE SYSTEM FAILS: You must indicate either'Yes'or'No' to each of the following: The following Criteria apply to large systems in addition to the criteria above: /lJ The system serves a facility with a design Bow of 10.000 gpd or greeter Range SYstwnl and Una system is a significant threat to public health and safety and the environment because one or mare of the following conditions exist: Yes No IN system is within 400 feet of a surface drinfting water supply the aysten is within 200 fast of a trt'butery to a surface drbd*q water supply the system is located in a nitrogen sensitive eras(Interim WeNheed Protection Area=1WPA)or a mapped Zone N of a pubic water supply well The owner or operator of any such system shop upgrade ON system In accordance with 310 CLIM 1S.304121. Please Consult the local regional office d the Departrnent for furthar inforr a"M revised 9/2/98 par 4of11 a SUBSURFACE SEWAGE DO pPOM SVSTW NSPECTiON FORM CHECKLIST Prepeny Ad&w Owner: Oats at bmpeofmc Check if the fdlowing have been done:Vow nerst a artha��'°�'Now to each of the latlow(n9= Vas/ No Ptrntdrty "M'an o was prd b1 to owner.occupant.or Board of Health. re _ None of the sysam eo' ti hew been pumped for at least two weeks and tl�aVa�hee badV er as part �lbw at water haw not boon introduced into the ayamn,races rates during that Period- L.arga vak#rMs or as hspaction• . ✓� /t As twit plans have bow eboind and examined. Note if they are not available with NIA. The faci ty or dwelling was inspected far signs of sewage back-up. The system does not receive non-ssn w Of UWUsWW waste Bow- _ The site was inspected for signs of breakout- / _ the Sal Absorption System.have been located on 1s , sib- y All systan comPoMn�•excluding The septic tank manholes were uncovered•opened.and the interior of the septic tank was inspected for condition of baffles a tees.rnatedal of eanstnrche^•dinwarians•dep�°f gam•depth of sludge,depth of sewn. The sae end loeadon of the Soil AbgwPd rt Systmn an the site has boon datennined based am _ Existing infonnadmL For asanipIs.Plan at B.O.H. patarreined in the Auld Of any of the failure eritaria related.to Part C is at I...approomnion al distance Is unseeep�l `16.30213011 V _ The fecOW owner(and ate•H&"Went from owner,were provided with irdonmatim an the proper niinanance of SubSurface Oisposd Systems- pateShcl revised 9/2/98 F SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM PART C SYSTEPA WFORJAATION Property Address: Ownrar: Daft of Kspection: FLOW CONOITIM RESIDENTIAL: 002190 flow: //0 q.P.d.lbodroam Nunnber of bedrooms Idesignl:� Nunnber of bediroans(scuu4 Total DESIGN flaw�ffpD Number of current residents: Garbage grinder(Yes or no): Laundry(separate s1lsteml Irss or nol--_ffS If yes. separate inspection required Larwrdry systan inspected (gas or sol y�$ Seasonal we(yes at no):_Ep Water meter readings.if ovaiil"past two year's usage fgpol: �v�A Sump Pump(Yes or no): &D Last date of occupancy:__r&—$S NT OOfNMBt Type of establishment: ' Design low: sod I Based on IS.2031 N Basis of design flow Grease trap present;(yes or Rol_ industrial Waste Molding Tank present:(yea at no)_ Non-sanitary waste discharged is the Tilt S system:(Yes or not Water meter readings.if evaisWs- Last date of occupamr OTME3t:10— be) '.ast date of occupancy: GENERAL ANFORNAT10N PueAP WG REGOROS aid saace of' S VT'rV064 1 .999 CNSTb%4 E 1r11 Fd r4 1 lCK) System pumped as part of inapectjon:(yea or no)_A/C) r N Yes.vokane pumped:_ X canons Reason for pmrpkW TYPE 9PSYSTIEPA eptie WWdistrbutlon boslsoa absorption system Slinglo Cesspool Overflow essspod Privy Shared system(yes or nol Of yes.attach pevioas inspection records.B any) VA Technology etc.Attack copy of up to deft operation and mdntarwnes convect Tight Tank Copy of DEP Approval Other APPNOMATE AGE of all compwmft.date irnatened Gf known)and smAce of information; _ /Q F9 Pe.orr R-Axcs Sewage odors detected when arriving at the she:(yes or no)A/d revised 9/2/98 hge6ef11 SUBSURFACE-SEWAGE DISPOSAL SYSTEM wsPECTION FORM PART C SYSTEM WFORMATM(coldmed) hopwtg Address: Owner. Does of kupeedow fBULMOM SEWER: (Locals an site plan) N 1 F...below grade: dp PVC other(explain) Matati-, of eonsohOetion:_cast iron_ Oft"we train p wore water vu0*ws0 or slwdon Wla Diameter of Igkape•ate.) Comments:(eondlton of Iohm..Vw evidence SEPTIC TANK:_ Rotas on site plan$ Depth below Wade: >� "Wesptain) la Marial of eomstrueflon:FOOMOU-n"d MwOuw If tank is metal.al,list sge__ vOl — is conWmed by Cerdf ele of Compliance_(Yes/N01 N Dimensions: f: Jr 7 a x A- 10 6~ be w S' Sludge depth: 011 Al --A C Drumnee from top of sludge to bottom of Outlet no or baffle• �q Soren thickness:.`_ Distance from top of scum to top of outlet we or bath: F1 Distance ham bottom of scum to bottom of outlet tea Or baffle:/ how dimensions were determined' ,�rrS;'��- Pv�j'�CT 10•� Cjneonrnen.4 d, for planpieg.condition of bier and Outlet tees Or baton.depth of flquid lewd in rdadon m outlet invert.atruewrel insegrity. evidence of lack -ate•$ E o.ti O�g'v .s Pit! �O.o A + �r r i v 4,r , L.E4 lC GREASE TRAP: .0ocow an site plan) Depth below grade: metal Fiberglass Polyethylene pgwiaxplainl flllaterial of construction:_concr§_ NI olmenaions: s"wn ttickGOU: olydee tee or baMe: . Distanee ham top of scum to Up et Dfsteree from bottom at SOON m battam of outlet tee a baffle:„ Date of lost pumpkg: Comments . motion of kdat and OOdet tees or baffles.depth of ft"Wd in ral"M to outet invert.~Ural integrihl. (reeomffm dadon for pumpin& evidence of lockage.etc-1 revised 9/2/98 Pate 7ett1 SUBSURFACE SEWAGE DISPOSAL SYSTEM NOPECTION FORM PART C SYSTEFA*W<NVAATM(ea tined) Ma"ty Address: Clweer: OWN a#inspecdon: TOM OR NOADBIG TANK: (Tank must be pumped prior to.or at time of.inspecdonl (Iocsrte an sits plan) Depth beknw grade: Material of wnstrmeaioe• m_am" Rbsrglass Polyethylene_otfneNespleirn) Oknensions. .---.gallons Design flow: 9allonsiday Alarm present Alarm leval Aknrnn in working order:Yes No Date of previous pumping: — — Caemants: Ieonddon of inlet tee.condtion of alarm and float awit tm ate) ownnuf m BOX:_ floeeto on site plan) Depth of liquid level above outlet invert: Car ments: (snots if kivd and distribudon in egmi.evidence of solids caryover.aridenea of leakage into or oral of bos.etc.) /t 7 X4 R crT d d/ / S E Q✓A- e/f�RY cdVFA Rotate on site phml rj1n Pw npe in waking order:Was or Not Alenms in working order(Yes or Nol Canmems: mots eondtlon of pump clamber.condition of pumps and appurto nces,ate.) revised 9/2/96 hraof11 su85uRFACE SM=DW)C Ys�asPECTION FORM SVSTW NFOf1MAI WWWW 4 'vrop.rer Address: owner_- Dear of = SOIL ABSOFN b- ration not ngw W.locadon may be aWos�ated by non-inwsive medwdst poeato on alto pw►. p • If not located.explain- Typs: bwWng pits.raanber:L G X Naefg chambers,nwWser.— bodd g Votaries.nundor. bectkq anew•numW.bngths leaching Nelda.nurnber.dNrension3: mow cesspool.number:__ Alternative system: Name of TachndM-- com"Nol": soil.condition of vagetatiom etc.) Own condtion of sal.signs of hydreiic faawe.level of porr8ng. denP e IF If N Mmme on ska plan) Number and contigursdon: Tapth-top of liquid to inlet invert: japth of soads layer: Depth of scum layer: Oknensions of cosspod: Materide of eonsvuedon: b dtcatien of groundwater. p of inflow as inspaetian) inw Icesspod must be pr�nped conments: (now can~of era.signs of hydrau6e faaure.161 of pendng'con66on o!vegutation.etc.) pocate on site plenl NIA: Matuieis of construction: Depth of eatids:- CawwywnU hydrauic fohne.bvd of parting.cand*m of vepetadoe, GI �condieom of cal.signs of i revised 9/2/98yofll I SUBSURFACE SEWAGE DISPOSAL SYSTEM MSPECTNM FORM PART C SYSTEID ViFiORMATIOR 1esa0noedl Prspowty Address_ Owrw: Ogee of, I FAR SKEMN OF SEWAGE DISPOSAL SYSTEM km*Wa des to st twt two pwMwwM fwfw m Isndn—k ar bondrnwks IwJ"r wills within IOW ILoests whop pjbk now supply conies info house! 5q`� h revised 9/2/98pfte iodu a;r:. SUBSURFACE SEWAGE DEPOSAL SYSTEHd INSPECTION FORM PART C Sys Em NPORMATION lcorrtira�) PropesW Address: Owner: Oats ad IraOeetion: NRCS Rgmwt nsnre Sal Type_ Typkd depdt tO Pdwate► USGS Den webd%visind Observation Waft checked ModeraRe Deep Groundwarter depth: Shallow SITE EXAM Sbpe Surface water Check cellar ShAm wags Estimated Depth to Groundwater7 Feet Plane in&cate OM_the medwds used to deternine High Groundwater Elevadoe: V Obtained from Design Plans On record Observed Site(Abutting Property.observation hate.basement sump etc.) V Detefromined from local conditions ✓/Checked with local Board Of hearth Checked FEMA Maps Checked pumping records Checked local exeevatws,installers used USES Dan .Describe hew you esabkshed tha'High Groundwater Elavatim Mobs eOMP141 eO J4'Tic f revised . 9/2/98 11d11 Please read this notice Purse: The information in this report is based on visual inspection of the listed property. This does not mean that that every defect was discovered or uncovered. This report does not offer nor imply a warranty to an defect to P Y rY Y the operation of this system. The process is to visually inspect, as much as possible,.the components of the septic system and to determine if this system meets the criteria outlined by this report cor<cerring Title Five regulations. This information is based from the conditions noted at the time.of the. inspection. There is no indication given as to the remaining useful years or if the engineered design flow is at present use of this dwelling. The use of this information is with the understanding that the above conditions are integral to this report whether it is from the buyer or sellers position. A copy of this report will be kept by me and is a available to all parties concerned. If you require further information, please contact me directly at any time. T. . hum ns s ROB6RTS l-78 TNs��c:rc;R - aaG - Y309 (l.Wt.Gd 04/25/97) p.ve 10 of 10 y - . : GENERAL NOTES TEST PIT #1 TEST PIT -*2 0 ESE 99.0 t,_E -- -� - �`_-�-- 1. ALL ELEVATIONS SHOWN ARE BASED UPON NGVD 17-771 TOPSOIL& I � 2. PITCH ALL LINES A MINIMUM OF 1I8 /FT, UNLESS $U6$0/L {{ � OO �� �r , N f ISPECIFIED. i l - OTHERWISE _ \ , I 2 - I 5 000 0 J 0 ® O � C,, C 0�0 I 3. ALL PIPES TO AND IN THE SYSTEM SHALL BE CAST � _ ,_ '� � l ; IRON OR SCHEDULE 40 PVC. __�� _21_�. 0 TANKS, DISTRIBUTION BOXES AND 4. ALL SEP TIC TA S , 000000 0 p ® 000000 -2 WHEEL c.y. !I LEACHING PITS SHALL. BE DESIGNED FOR H 0 GROUND :, 'ti c0 7 (� © O 0 0 00 i MEDIUM t warER -- - , 00 0 0 LOADINGS WHEN UNDER PAVING. 00 � o0 © C4000� aa,.a i.r 0 0 0 0 O SAND 000003, C� O 000000 5. REMOVE ALL UNSUITABLE MATERIAL BENEATH THE o" - - ATI NS QF THE LEACHING PIT FOR 14 ►. OG O 0 ® U ;6, O 0 CI00 INVERT ELEV O _ CLAY - A__: DISTANCE OF 1OFT AND BACKFILL WITH CL 861 a - - - , t_ . . , TRIBUTION BOX 000 C j u ® O 0 c � o oco A o s TYPICAL DIS aG„ h FREE SAND 5 GRAVEL HAVING A PERCOLATION RATE WATER 85.0 /4 LiC?:Ji LEVEL- OF 2 MINUTES PER INCH OR LESS. 840 I NOT TOSCALE i� —6-0 I5 � I - F HEALTH MUST T 6. THE BARNSTABLE. BOARD 0 NO, F DISTRIBUTION BOX AND -'�- BE NOTIFIED WHEN THE .SYSTEM IS NEAR COMPLETION GAL. REINFORCED SEPTIC TANK BY P6458 AND PRIOR TO BACKFILLING. ACME PRECAST OR EQUAL. LEACHING PIT OBSERVATION PIT TYPICAL /000 GAL. SEPTIC TANK TYPICAL LEAC OBSERV �-" 7. UNLESS OTHERWISE' NOTED, ALL SYSTEM COMPONENTS A DANCE WITH TITLE NOT TO SCALE SHALL BE INSTALLED IN CCOR PERCOLATION RATE=2M/N/INCH NOT TO SCALE OF THE STATE SANITARY CODE AND ANY LOCAL lt/ TE" TANKS REINFORCED THROUGHOUT WITH �b , OBSERVATIONS BY GERRY DUNNING O +C� 1 RULES WHICH MAY APPLY. " mot. 9 � 10 ENGINEER TO BE NOTIFIED PRIOR TO BARNSTA6irEBOARD OF HEALTH ELECTRIC WELDED WIRE WITH 24-1/2 ab APE 8 ISLANDS ENG/NEER/NG EMBEDDED STEEL RODS IN TOP & BOT- INSTALLATION TO VERIFY SOIL CONDI- 8. 'CONTRACTOR IS TO NOTIFY -ENGINEER, PRIOR TO THE ENGINEER C , TIONS. INSTALLATION OF,SEPTIC SYSTEM, OF ANY DISCREP-- TE I 4 00 PS.I. `TEST. DATE: 5120/87 TOM. CONCRETE S ,0 ANCIES BETWEEN TEST PIT RESULTS AND FIELD - N CONDITIO S. • LEACHING • 9. ACCESS MANHOLES TO SEPTIC TANKS AND LE C PITS TO BE BUILT UP TO 12 .INCHES BELOW FINISH GRADE. LOT TOP OF LOT 7 FOUNDATION ELEV.= 115.00' GRADE OVER LEACHING` FINISH .GRADE FINISH GRADE FINISH GR D OV , 6/660 S.F, f OVER "D" BOX AREA ELEV.= p9.0 FINISH'GRAOE OVER TANK , ELEV.=109.8, f ELEV=1�2.5 ELEV. ///.0 r EXIST ,,... LINE SEAR.MG DISTANCE GROUND 77'51 '40 'I✓. 50.36 1 N SER �, 1 ,, 3 „ r __ - --- - - - x �8 x 4 2 S 41 14 59 N 30.56 ��_. ._:Y�_ �' - _ 1: � _ 6 _ - :�,xA. WASHED STONE 3 N 77 51 40 N 50.36 I NV.- /05.0 _ �-.:,. _..�,. 4 , N J2'OB'20 E 30.00 ' I NV.= 104.37' r _µ _ �.; 4R• -`. INV.=104.75' AL_ INV.=/04.50'. /ODO G DIST BOX •off .. . . ....... 0 3/4 x 11/2 REINFORCED ! TO Bc FV�r";� a ...... .. . . ....... o WASHED STONE /22 CONCRETE B ....STAB__:-._) � ...... .. . . ....... BOTTOM OF PIT .'� be SEPT i C TANK' _ O' 12o INV. /02.0 ELEV.=_ ` ' , < TC RE LEVEL B STABLE) ae � n4 /rr • no 2 '_I /08 TYPICAL SEWAGE SYSTEM PROFILE PRECAST LEACHING PIT as - (TO BE LEVEL 8�, STABLE) ►/10 g • fog NOT TO SCALE H4 LEGEND y ;. MAP SECTION PARCEL _LOT ADDRESS 4 //o / EXIST CONTOUR � .-_ — 8 8 60 /4- 7 PROPOSED CONTOUR _ EXIST SPOT ELEVATION $ �C 0 PROPOSED xS: OT ELEVATION 8 +O r � IS T F�G� G haZa � ZONE Q -' ZONING p��TR�C � o q � foe L 0T PERCOLATION TEST m W �- R F ,� ) RVAT I N PIT — -- sx •©- o C. BSE E� REY/SED /O/2/89 J-S-P. �/SE ,Sr7Z?ACK VMENSIONS @ REr WALLS - /oo DWELLING � ?� � � PROPOSED _ LOCATION OF DWELL G DESIGN CRITERIA ��'Ao �. A SYSTEM R01;, � & SEWAGE DISPOSAL /08 F BEDROOMS 3 os NUMBER O BEDROO P: �- j P.A rAOND ti, °°- PERSON .PER BEDROOM _ t LOT 7- R VD? ROAD /04 PER R PERSON PER DAY __55._ GALLONS � - >6` H I I U I R E D 33-0_GPD SAX �: - �4 EAR Nc EQ. , �� , II��1 RS TONS /�I/L L S MJ. 96. �: BREAKOUT CALCULAt/ON 1 ,549 GPD 6 LEACHING �'ROVIDED 2B.S X /50 =3J.6 c 38 .. O.K. DISPOSAL YE o ., APPLICANT . _ ENG I NEER �i ARP�;Vv ,_�J�.�INEERIrJG INC. T/M07�HY ,LEEDHAM � _ �-a ;: R SIGNS v ,r RIV�- SUITE B SEWER DE RC_ f?O. BOX 687 1� E D �► n ,�, r� f 49 ivIASHPLE, PIA C�649 r _ ppymo M,4SHPEE, MA. 026 04D SIDEWALLr 2#-X 5x6x2.5•,.•,d.••_ 47/ G.P.D. . _ ;, rl�l�i:2t5834 ate. . � I k a ( -, S - p _. A DATE. , SHEET , • - 78 6.P.D. SCALE :E M 'S ,, ,. s t1., ;,I I�_;,NN �'•PT 29 /989 OF TOTAL= �:549 GPD ;K BY APPD. DY PLAN NO, I DRAWN BY CHECKED . i �'/S✓R RER H E:R 6.3.�' . PLAN :SCALE 50 JS _ / - �; ; _ V _ ...ate - .. ,.... - . ....:ate.,_,,,. r 4 I C _ i ..f GENERAL NOTES TEST PIT #1 TEST Pie _�2 „ I 8 - 6 { ;�. ELEV = 9.0 E?.:E`V, ', �---- P II 1. ALL 'ELEVATIONS SHOWN ARE BASED UPON NGVO TOPSOIL a 1 I , i SUBSOIL 2 PITCH ALL LINES A MINIMUM OF 1/8u FT. `UNLESS __T + J OTHERWISE SPECIFIED. r p n , a I a r I 2 cv CAST 5 , a �: < 3. ALL PIPES TO AND 1N THE SYSTEM SHALL BE S j ' IRON OR SCHEDULE - 0 PVC.00 0O3 0 0 000G00 I I I , i' _ 0 0C� ® OO 'cl00 00 00 0 4. ALL SEPTIC TANKS DISTRIBUTION BOXES, AND O , I I i 000 0 0 © 0 �; c 0 0 00 ,. GROUNb I I 0 LEACHING PITS SHALL BE DESIGNED FOR H 2O WHEEL { MEDIUM wA r R . 0 ID a 0 0 0 0 0 0 0 00 y 00 0 LOADINGS WHEN .UNDER PAVING. , I Aar. 000 0 0 000000 it S4N0 A UNSUITABLE MATERIAL BENEATH THE „ 000 J ,) ® 0 0 � 0 0 0 00( 5. REMOVE ALL S 10 + - 14 I ELEVATIONS OF THE LEACHING PIT FOR I ! -s- 3;, r. 000, 00 ® ©_O 0 0 0 000 INVERT `ELEV 0 � TYPICAL DIS 1 o oro A DISTANCE of 1OFT. AND BACKFILL WITH .CLAY I — TRI BUT{ON BOX o0o c � � ® o � o . ,=0 h FREE SAND 8GRAVEL HAVING A PERCOLATION RATE 74 WA7FR 85.0 i , ; -i- _ DQJIC _VE. . INCH R LESS. (( OF 2 MINUTES PER 0 S. T T SCALE " /5� 84.0 I I NO O -- 6-0 . .�:_ T 6 THE BARNSTABLE BOARD OF HEALTH MUST NOS E DIS; RSBUTION BOX AND _ � I r SYSTEM IS NEAR COMPLETION P BY BE NOTIFIED WHEN THE P6458 GAL. REINFORCED SEPTIC TANK: R AND PRIOR TO BACKFILLING. ACME PRECAST OR EQUAL: PIT _ OBSERVATION PIT TYPICAL /000 GAL.. SEPTIC TANK I TYPICAL LEACHING " 7. UNLESS OTHERWISE NOTED, ALL SYSTEM "COMPONENTS INSTALLED IN ACCORDANCE WITH TITLE N: I SHALL BE S PERCOLATION RATE-2M/N//NCH NOT TO SCALE NOT TO SCALE OF THE STATE SANITARY CODE AND ANY LOCAL OBSERVATIONS BY GERRY DUNNING NOTE TANKS REINFORCED THROUGHOUT WITH �b RULES WHICH MAY APPLY. , W/ 4- f �j• 9 �►' 10. ENGINEER TO BE NOTIFIED PRIOR TO aAR/vsrA�BOARD OF HEAL,T+� ELECTR,C ELDED WIRE WfTH 2 2 1, ab DI NOTIFY -ENGINEER PRIOR TO THE i ENGINEER• CAPE 8 ISLANDSENGINEERING EMBEDDED STEEL RODS IN TOP 81 BOT INSTALLATION TO VERIFY SOIL CON 8. CONTRACTOR IS TO , I INSTALLATION OF SEPTIC SYSTEM , OF ANY DISCREP DATE: 5120187 TOM. CONCRETE IS 4,000 PS.I. TEST. TIONS.' I ANCIES BETWEEN TEST PIT 'RESULTS AND FIELD CONDITIONS. 9. ` ACCESS MANHOLES TO SEPTIC TANKS AND LEACHING PITS TO BE BUILT UP TO 12.INCHES BELOW FI NISH I GRADE. ,. I = LOT qf { f TOP OF LOT- 7 FOUNDATION ELEV. //5.00 FINISH GRADE FINISH GRADE OVER LEACHING S ,, ..- FINISH GRADE" S 6/660 .F♦ _ FINISH GRADE OVER TAN K OVER I'D" BOX AREA ELEV.= pg.o' ELEV /IZ,3 ELEV.: ../1/.O ELEV.=/09.8 LINE BEAfaIN c DISTANCE EXIST. GROUND J N 7T_'5t '40"N 50.36 en . " /SER♦ It 3/ . 4 W 50.36 ;r l.+.S. • IN . /o .a _ �>s l�lAS�iEU ST�JNE 4 N i2 OB 20 ,E 90. 00 NV. o , T I NV. /04.2 � »..... .. . " INV, '" I �" n o'b •'..•.• •• w • •••••• M 3 11/ODO GAL IN —B 2„ /22 REINFORCED (TO . . ....... o I � r e o . ... . . WASHED STONE CONCR�TE , 11e SEPTIC TANK ......... ..:..... BOTTOM OF P1T . /20 5 l / �b c (TO BE LEVEL B STABLE) INV. /020 U ELEV. 96.0 116 , h L 2 4 2 1 114 C/2 //O /oe PRECAST LEACHING PIT TYPICAL SEWAGE SYSTEM PROFILE I r� ', _ Ios (TO BE LEVEL a STABLE) 114 ` 104` NOT TO SCALE / i LEGEND MAP SECTION PARCEL i�OT ADDRESS //off EXIST. ;CONTOUR __ �_ 8 - _ 60 PROPOSED CONTOUR I /12 a ` ELEVATION EXIST SPOT $ O P P SPOT ELEVATION 8; PROPOSED S 0 + 0 � � ,. 60 �' � i�TR T F._.CiCD ,hiZHrcG ZONE I 9 � /oz L-OT S PERCOLATION TEST m ZONING U IC _F F,, RF /3x .91 o6 o OBSERVATION PIT �— REt//SED IO/2/89 J.S.P. �V1SE SE78.QL�C U'MENS/ONS �4 RET. WALLS ��p ?Q /00 //0 9a PROPOSED LOCATION OF DWELLING no DESIGN CRITERIA SEWAGE DISPOSAL SYSTEM 4 E78i Fdi ioe 3g r os NUMBER OF BEDROOMS cc'.a RAYMOND % I ,_:Z s /06 ,aa `°- PERSON PER BEDROOM �,:;,, 04 L 0 T 7.. RIVER ROD / GALLONS, R PERSON AY _55_: t LLO S PER ERSO E D '�FCISjr "' ?� REQUIREDcr , _330_GPD s� LEACHING + ko, �_ gI `V:31 i T / /WIJ I IV 9B - l.e 9 ,+ BREAKOUT CA M�RS TONS V� /Y/�L� L-S /V/A. •,3�; I 5¢9 GP0. 6 - LEACHING PROVIDED 01 p X150 - 31.6 < 38 .. 0.K. z8 DISPOSAi YES_. r 'ENGINE ER . �$ APPLICANT ' E E f R �d` AR ,CVr Er�1C�1NtE1If�4G ,fVC. .; ,a _ � TIMOTHY.L EEDh'AM d••"..- SEWER ES f DESIGN - �-� � ._ FrQD ��s 1t, .,, ,FE OR,v_ SUITE g � P.O. BOX 6'B7 +u ,J1ASH 'EEA C�649 � ��Yh�oe�» M` SHPEE MA. 02649 , . SIDEWALL 2�x 5x6x2.5 47/ GP.D. . , 2 +0 4 9 , , » ... .. - ¢ A DATE; ,HEFT - X; r LO 78 G.P,D. Ct BOTTOM 4I` . 5` � sr�• �' ♦p / - i t i .APT 29 1989 �a� TOTAL- Y � ��l 9B 549 GP0 �:' �P 1Aoi r AI LAN :NO. DRAWN BY CHECKED BY . D: BY F . OR w €m 50 a5PLAN SCALE 633 I