HomeMy WebLinkAbout0931 RIVER ROAD - Health 931 River Road
Marstons Mills
_ A= 044-013
i
TOWN OF BARNSTABL-E
LOCATION 9 51 AIf4 8:6,$ f2,uK 12 04J SEWAGE#
VILLAGE M .A4- ?I1 ASSESSOR'S MAP&PARCEL (&r—M/
INSTALLERS NAME&PHONE NO.�jt w"d
SEPTIC TANK CAPACITY /.fO U 14 /O
LEACHING FACILITY:(type) dO !;g F'(size) //, X 3 24
NO.OF BEDROOMS
OWNER o <
PERMIT DATE: COMPLIANCE DATE: D -
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility WO A/ Feet
Private Water Supply Well and Leaching Facility(If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
FURNISHED BY
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M ' 931 River Rd
Property Address
Doris Childs
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 7/18/12
page. City/Town State Zip Code 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 end of the form.
Important:When filling out A. General Information
on the computer,
tforms AOF4 '
,VfV� � �``� �S,H of Mgss•,,G
use onlythe tab .�y$�`.••'
key to move your 1. Inspector: ;ors:• ••'':;��yG
cursor-do not ate: JAMES
use the return James D Sears �; :m e
ke Name of Inspector :y
y.
'*
CapeWide Enterprises L.L.C. C,
Company Name �RT1 �
153 Commercial St i0��'F 5 I N Sp�G``\\���
Company Address ar""R"►t��
fan
Mashpee Ma 02649
City/Town State Zip Code
508-477-8877 S1623
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
7/18/12
spector's Signature Date
The system inspector shall submit a copy-of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of-the DEP:Tie 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.
.W t' 1 1
t5ins•11/10 _Title 5 Offidal Inspect'W. Subwl.SewageML
l System•Page 1 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
931 River Rd
Property Address
Doris Childs
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 7/18/12
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments: _
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
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 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.
❑ Y ❑ N ❑ ND (Explain below):
t5ins-11110 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
931 River Rd
Property Address
Dons Childs
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 7/18/12
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
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 ❑ ND(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):
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
T the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
. } 15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
931 River Rd
Property Address
Doris Childs
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 7/18/12
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier,if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for 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
❑ 0 Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
1100
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
931 River Rd
Property Address
Doris Childs -
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 7/18/12
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large'system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you 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
❑ D 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.
t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
931 River Rd
Property Address
Doris Childs
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 7/18/12
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Rump Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�< 931 River Rd
Property Address
Doris Childs
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 7/18/12
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
The system is a 1500 gal precast tank d box and 20 Biodiffuser
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage 2010-17,000 gal
g ( y g (gpd)) 2011-14,000 gal
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: presentDate
Commerciallindustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., 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:
t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
931 River Rd
Property Address
Doris Childs
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 7/18/12
a e. City/Town State Zip Code Date of Inspection
P9 P P
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: 4/9/12
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/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
931 River Rd
Property Address
Doris Childs
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 7/18/12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
2008-permit#2008/396
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 30"feet
Material of construction:
❑cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
pipeing is 4"pvc sch 40
Septic Tank(locate on site plan):
Depth below grade: 2'
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1500 gal precast
lotSludge depth:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
931 River Rd
Property Address
Doris Childs
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 7/18/12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
29"
Scum thickness
Distance from top of scum to top of outlet tee or baffle
8"
Distance from bottom of scum to bottom of outlet tee or baffle
18"
How were dimensions determined? tape plan asbuilt sluge judge
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank at working level w/covers at 1' in and out let tees tank at 2' no sign of over loading or leakage
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
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
931 River Rd
Property Address
Doris Childs
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 7/18/12
page. City/Town State Zip Code Date of Inspedion
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level.' Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is co attached? ❑ Yes No
P 9 PY ❑
t5ins•11110 Title 5 official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
U"
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
s�o 931 River Rd
Property Address
Doris Childs
Owner Owner's Name
information i e
required for every Marstons Mills Ma 02648 7/18/12
page. Cityrrown state Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
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.):
D box is 16"x21"28" below grade w/cover at 8",four lines out box is clean and solid no sign of over
loading or solid carryover
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(mote condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-11110 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
931 River Rd
Property Address
Doris Childs
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 7/18/12
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 20
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields , number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is four rows of five Biodiffuser camera out to leaching t.h. and prob at leaching no sign of
over loading
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
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
s '"( 931 River Rd
Property Address
Doris Childs
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 7/18/12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
I m
DATA
Commonwealth of Massachusef#s
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
931 River Rd
Property Address
Doris Childs
Owner Owner's Name
information is required for every Marston Mills Ma 02648 7/18/12
page. Citylrowrn state Zip Code Date of tnspectlon
D. System Information (corn.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
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`fi /fiZ a9.3 &Z Z1•0
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1, 114 3(o•2 °Y 37.•'
ray 31.0 &r 33.1
8b 3r..O
61 3$ a
11 t S.1 a /- a''?
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y� 931 River Rd
5 y
Property Address
Dons Childs
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 7/18/12
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 11 +
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: 9/12/08
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:
T.H. on plan no water at 11+'
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 16 of 17
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
931 River Rd
Property Address
Doris Childs
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 7/18/12
page. Cityrrown State Zip Code Date of Inspedion
E. Report Completeness Checklist
® Inspection Summary:A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
{
relr>s•1
1/10 We 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 17 of 17
TOWN OF BARNSTABLE — UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION
MAP NO. t.� "/�� PARCEL N0.
ADDRESS OF TANK: ^� ' + VILLAGE.
MAILING ADDRESS ( IF DIFFERENT FROM ABOVE) :
OWNER NAME: �� =-i '`'r F` PHONE:
—rNSTAL'LAT-Y0IV7—DWT-E-s X
INSTALLER ADDRESS: f ; fr /;J -CERT.140.
t'
*TANK LOCATION:
`f (DCMOR Z UR TANK LOQAMr-7 —
S TH RCOPQCT TO mLl I LD I NO)t CC
CAPACITY TYPE OF TANK. c � AGE YRS. FUEL/CHEMICAL
L
TESTING CERTIFICATION [ ] PASS [ ] FAIL DATE
i -
' LEAK DETECTION C ] CHECK IF N/A TYPE/BRAND
ZONE OF CONTRIBUTION [ YES -[ ] NO ` DATE TO BE REMOVED
FIRE DEPT. PERMIT ISSUED C ] YES' C ] "NO DATE
CONSERVATION [ ] CHECK IF N/A DATE r
BOARD OF HEALTH' TAG N0•: C DATE1491"l , l
5 -
PLEASE PROVIDE A SKETCH SHOWING THE TANK LOCATION ON THE BACK OF THIS CARD
t
TOWN OF BARNSTABLE
�PypG TH E ro�yo
' y OFFICE OF
HAHasTABLE,M{IRB. BOARD OF HEALTH
i63q. ` ' 367 MAIN STREET
`0 MAY
HYANNIS. MASS. 02601
"A 04-7
1989
Dear °
l..
Enclosed is brass valve tag #_ Please attach to
the fill pipe of your underground tank .
You must do the following as indicated:
Remove your tank. I have enclosed information for you
J r��
regarding tank removal . I�E,WoVh C.- �>Y �(� E S ` �O
---- Have your tank tested starting -__-_____ . You must test
during the 10th, 13th, 15th, 17th and 19th year and
annually thereafter. Removal in the year I
have enclosed information regarding tank testing. ** In
order to have your tank tested you must first contact an
engineeriiig company (see attached) to have a monitoring
well installed. Once the monitoring well has been
Installed you can then call 362-2511 , Ext.334 and ask
for Charlotte Stiefel or George Heufelder at the
Barnstable County Health Department, to have your tank
tested via the Soil Vapor Analysis Test. Currently, the
test is done free of charge under the auspices of an EPA
grant.
____ Due to the unknown age of your tank we must presume it
is twenty (20) years of age. You must have it tested
every year and remove it by the year 1993 . To have it
tested please follow the procedure as indicated above
from the ** (asterisk) on.
If you have any questions please feel free to call me at 775-
1120, Extension 183 .
. Thank you,
Donna Hiorandi
Health Inspector