HomeMy WebLinkAbout0095 TUPELO ROAD - Health 95 Tupelo Road, Marstons Mills
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TOWN OF BARNS TABLE
,LOCA`I ON /fi"a' I SEWAGE#
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SEPTIC TANK CAPACITY AQ.&i.;z
LEACHING FACILITY: (type)_ ( ��J I (size) -oc) _
NO.OF BEDROOMS
BUILDER COWNER
PERMITDATE: COMPLIIANCE DATE:
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Separation Distance Between the: f'404
Maximum Adjusted Groundwater Table and Bottorff'of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
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COMMONWEALTH OF MASSACHUSETTS 49
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION]FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE IDISPOSAL SYSTEM ]FORM
PART A
CEIRTIFICATION
Property Address: 95 TUPELO
MARSTONS MILLS ��".�,3�a C:)
Owners Name: LEMOINE ; CD
Owner's Address: �n 1n
Date of Inspection: 11/14/05 N
c j ti rn
J
Name of Inspector: (please print) Douglas A.Brown
Company Name: Douglas A.Brown Septic Inspections
Mailing Address:P.O Box 145
Centerville,MA 02632
Telephone Number: 508-420-4534
CIElRTI1FICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system:
X Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: /� Date: 11/14/05
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving,
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
Conditions of use.
Title 5 Inspection Form 6/15/2000 page 1 Revised on 10/31/2000
Page 2 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
TS
SUBSURFACE RFACIE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
(PART A
CERTIFICATION (continued)
Property Address: 95 TUPELO
MARSTONS MILLS
Owner's Name: LEMOTNE
Owner's Address:
Date of Inspection: 11/14/05
inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X I have not found any information winch indicates that any of the failure criteria described in 3 10 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 Pase'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 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.
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
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
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 95 TUPELO
MARSTONS MILLS
Owner's Name: LEMOINE
Owner's Address:
Date of Inspection: 11/14/05
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 15.3030)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ the system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well".Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
Page 4 of 11
OFFICIAL INSPECTION ]FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION]FORD][
PART A
CERTIFICATION (continued)
Property Address: 95 TUPELO
MARSTONS MILLS
Owner's Name: LEMOINE
Owner's Address:
Date of Inspection: 11/14/05
D. System)Failure Criteria applicable to all systems:
You must indicate"yes or no to each of the following for all inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 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
X Any portion of the SAS, cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 3 10 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure,
E. ]Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes" or no to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone 11 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
yeg'm 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
Page 5 of 11
OFFICIAL INSPECTION]FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 95 TUPELO
MARSTONS MH LS
Owner: LEMOME
Date of Inspection: 11/14/05
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 Have large volumes of water been introduced to the system recently or as part of this inspection?
X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out?
Were all system components,excluding,the SAS,located on site?
X _ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
_ X Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
X _ Existing information. For example, a plan at the Board of Health.
X _ Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of distance
is unacceptable) [310 CMR 15.302(3 ))(b)]
5
Page 6 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
]PART C
SYSTEM INFORMATION
Property Address: 95 TUPELO
MARSTONS MILLS
Owner's Name: LEMOINE
Owner's Address:
Date of Inspection. 11/14/05
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 64 Number of bedrooms(actual): 14
DESIGN How based on 3 10 CMR 15.203 (for example: 110 gpd x#of bedrooms): 116,10
Number of current residents:j
Does residence have a garbage grinder(yes or no): -yeS
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use: (yes or no): NO 3 ' ► 3�VfrG^yE�
Water meter readings,if available(last 2 years usage(gpd)): c 11 7 3;OCO C,
Sump pump (yes or no):
Last date of occupancy:
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no):
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
Septic tank,distribution box, soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components, date installed(if known)and source of information:
Were sewage odors detected when arriving at the site (yes or no)? NO
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 95 TUPELO
MARSTONS MILLS
Owner's Name: LEMOINE
Owner's Address:
Date of Inspection: 11/14/05
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: cast iron 40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: (locate on site plan)
Depth below grade: 12"
Material of construction: _concrete_metal_fiberglass polyethylene
other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no): _(attach a copy of
certificate) f
Dimensions: 10WIAI i 5-no J)a 110
Sludge depth: TRACE
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: TRACE
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:
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 LOOKS STRUCTUALLY SOUND AT THIS TIME
GREASE TRAP:_(locate on site plan)
Depth below grade:_
Material of construction: _concrete metal_fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity;liquid levels
as related to outlet invert,evidence of leakage,etc.):
Page 8ofII
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 95 TUPELO
MARSTONS MILLS
Owner's Name: LEMOINE
Owner's Address:
Date of Inspection: 11/14/05
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):
I
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alzxm and float switches,etc.):
DISTRIBUTION BOX: X (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 solid)carryover,any evidence of
leakage into or out of box,etc.):
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Page 9 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 95 TUPELO
MARSTONS MILLS
Owner's Name: LEMOINE
Owner's Address:
Date of Inspection: 11/14/05
SOIL ABSORPTION SYSTEM(SAS): _(locate on site plan,excavation not required)
If SAS not located explain why:
Type
)( leaching pits,number: G 00 b C-1
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.): , 1,
� � tics inn a MA f %V% G-d e
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
� r
Page 10 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 95 TUPELO
MARSTONS MILLS
Owner's Name: LEMOINE
Owner's Address:
Date of Inspection: 11/14/05
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.
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Page 11 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM ] INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 95 TUPELO
MARSTONS MILLS
Owner's Name: LEMOINE
Owner's Address:
Date of Inspection: 11/14/05
SITE EXAM
Slope:
Surface water:
Check cellar:
Shallow wells
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
BORTOLOTTI CONSTRUCTION,INC. ro 2 19
765 WAKEBY ROAD,MARSTONS MILLS,MAI 02648 °Ttio�sr 9,
508-771-9399 508-428-8926 FAX: 508-428-9399 (P FPtgB�F +4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM L
PART A 9
CERTIFICATION
Property Address: %s�
L
Date of Inspection: Inspector's Name: O /
Owner's Name and Address:
CERTIFICATION STATEMENT:
I certify that I have personally inspected the sewage disposal system at this ad ress and that the informa-
tion reported below is true,accurate and complete as of the time of inspection!The inspection was per-
formed based on my training and experience in the proper function and maintenance of on-site sewage
disposal stems. The System:
Passes
Conditionally Passes
Needs Further E ation B th ocal Aproving Authority
Fails
Inspector's Signature: Date:
The System Inspector shall submit copy of this inspection report to the Approving authority within thir-
ty(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 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.
A)SY EM PASSES:
I have not found any information which indicates that the system violates any of the failure
criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated
below,
B)SYSTEM CONDITIONALLY PASSES;
One or more system components need to be replaced or repaired!. The system,upon comple-
tion of the replacement or repair,passes inspection.
Indicate yes,nor,or not determined(Y,N,OR ND). Describe basis of determination in all instances. If
"not determined",explain why not.
The septic tank is metal,cracked,structurally unsound, shows substantial infiltration or
exfiltration,or tank failure is imminent. The system will pass inspection if the existing sep-
tic tank is replaced with a conforming septic tank as approved by The Board of Health.
Sewage backkup 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):
- 1 -
i
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INS ECTION FORM
PART A
CERTIFICATION (continued)
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:
The following criteria apply to a large system in addition to the criteria labove:
The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant
threat to public health and safety and the environment because one or more of the following
conditions exist:
The system is within 400 Feet of a surface drinking water supply
The system is within 200 Feet of a tributary to a surface drinking water supply
The system is located in a nitrogen sensitive area Interim Wellhead Protection Area
(IWPA)or a mapped Zone 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. Pilease consult the local
regional office of the Department for further information.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
i
Check if the following have been done:
1/ Pumping information was requested of the owner,occupant,and Board of Health.
yNone of the system components have been pumped for atleast two eeks and the system has
been receiving normal flow rates during that period. Large volum two,
of water have not been
introduced into the system recently or as part of this inspection.
L/As-built plans have been obtained and examined. Note if they are not available with N/A.
_4ZThe,facility or dwelling was inspected for signs of sewage back-up.
/The system does not receive non-sanitary or industrial waste flow.
---{�T� he site was inspected for signs of breakout.
�AII system components,excluding the Soil Absorption System, have been located on site.
_The septic tank manholes were uncovered,opened, and the interior of the septic tank was in-
spected for condition of baffles or tees, material of construction,
6l dimensions,depth of liquid,
pth of sludge,depth of scum.
hee size and location of the Soil Absorption System on the site has been determined based on
existing information or approximated by non-intrusive methods.
-3-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST(continued)
The facility owner(and occupants, if different from owner)were provided with information on
the proper maintenance of Subsurface Disposal System
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
/ FLOW CONDITIONS
RESI .Design Flow: VVQ gallons Number of Bedrooms: Number of Current Residents:
Garbage Grinder: a Laundry Connected To System: Seasonal Use:
i
Water Meter Read gs@[ , ailable:
Last Date of Occupancy -
COMMERCIALODUSTRIAL*,Jv
Type of Establishment:
Design Flow: gallons/day Grease Trap Present: (yes or no)
Industrial Waste Holding Tank Present:
Non-Sanitary Waste.Discharged To The Title V System:
Water Meter Readings,If Available: Last Date of Occupancy:
OTHER: Describe)
Last Date of Occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source orinform5tion:
System Pumped as part of inspection:_41fyes,volume ped: gallons
Reason for pumping:
TYPE F SYSTEM:
Septic Tank/Distribution Box/Soil Absorption System
Single Cesspool
Overflow Cesspool
Privy
Shared System(If yes,attach previous inspection records, if any)
Other(explain).
APPROXIMATE AGE of all cgTponents, to installed(if known)and source of information:
Sewa a odors detected when arriving at the site
-4-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
GENERAL INFORMATION (continued)
SEPTIC TANK:
Depth below grade: Material of Construction: concrete metal FRP_Other
(explain)
Dimisions: . Sludge Depth: Scum Thickness:
Distance from top of sludge to bottom of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid
lev in re tion too tlet invert,structuralintegrity,evi nce of leakage,etc.) [ ' 1/ lh
41
"/
GREASE TRAP:_
Depth Below Grade: Material of Construction:—concrete—metal FRP_Other
(explain)
Dimensions: Scum Thickness:
Distance from top of scum to top of outlet tee or baffle:
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.)
TIGHT OR HOLDING TANK..ZJ
Depth Below Grade: Material of Construction:_concrete_metal_FRP Other(explain)
Dimensions: Capacity: gallons Design Flow: gallons/day
Alarm Level:
Comments:,(condition of inlet tee,condition of alarm and floiat switches,etc.)
DISTRIBUTION BOX: _
Depth of liquid level above outlet invert: (�{ 4L e
Comments: (note if l 1 and dist;ibutio is equal, idenL�'of solids carryover,evidence of lea ge into
or o of x,gtc.)
PUMP CHAMBER: ,
Pump is in working order:
Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.)
-5-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
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:
Leaching pits,number: Leaching chambers, number: Leaching galleries,number:
Leaching trenches, number, length:
Leaching fields, number,dimensions:
Overflow cesspool,number:
Comments: (note condition of soil,signs of hydraulic fa' a lev of pondi ,condition of ve etado ,
etc.) -
CESSPOOLS:
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 soilk,signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)
PRIVY:
Materials of construction: Dimensions:
Depth of Solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)
-G-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (conlinucd)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to atleast two permanent references, landmarks or benchmarks.
Locate all wells within 100 Feet.
3 0 '
301 3P
DEPTH TO GROUNDWATER:
Depth to groundwater: Feet
Method of Determination or Ap roxi ation: /O�//�1� Gt' Ile"
7c im ; m 5
-7-
; ! TOWN OF BARNSTABLE
LOCATION 46 T A '`CL SEWAGE #
VILLAGE-f Y\ArSfon 5 ASSESSOR'S MAP & LOT
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INSTALLER'S NAME & PHONE NO. SCd�
SEPTIC TANK CAPACITY J�^CO
LEACHING FACILITY:(type) l�j )5 ,(sizes)_ s
_PRIVATE WELL OR P:U LICF,
WAT
NO. OF BEDROOMSAJJ
BUILDER OR OWNER 1'C1e-, �� 1n
eb
DATE PERMIT ISSUED:__
DATE COMPLIANCE ISSUED_ -Ll 1
-1 7 /
%VARIANC:E GRANTED: Yes No s
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THE COMMONWEALTH OF MASSACAUSETTS
BOARD OF HEALTH
--------..........OF.... ...................................
Appliration for Uhqpoiial Morks Tomitrurtion ramit
Application is hereby made for a Permit to Construct (,K) or Repair an Individual Sewage Disposal
System at:
...mea_�_ .......anall........
. Lit's
.................................... .........................................q-----------------------------------------------------
Location- ddress or Lot No.
- •�.....�0----- ........... .......q=.......
........ erb .................
f4 _wn,................................................ ..............r Address
..Tz---------�.,-5,c&_ ...*-----------------------
Installer Address
M ess
C4 Type of Building Size --------Sq. feet
U
Dwelling—No. of Bedrooms... ................................Expansion Attic VD) Garbage Grinder (Ni�
Other—Type of Building WOM's.
...... No. of persons_____ Z................. Showers (2) — Cafeteria ('eo)
PL4Other.fixtures -------- ..............................................................................................................................
Design Flow...........4#W....114............gallons per person per day. Total daily flow...........H.4.0......................gallons.
1:41 Septic Tank—Liquid capacity.U> gallons Length.-Ii2........ Width......4?...... Diameter________________ Depth__ ..........
Disposal Trench—.\To. JUD-MY--- Width____________________ Total Length..__.__.____._.___._ Total leaching area--------------------sq. f t.
Seepage Pit No_____________________ Diameter_._.._._____________ Depth below inlet____._.._.._.....__. Total leaching area..................sq. ft.
Other Distribution box (y() Dosing tank ( ) N -Percolation Test Results Performed A...iA C............................... Date-----14- �s—-----------
Test Pit No. 1_44—.2.....minutes per inch Depth of Test Pit... ...... Depth to ground water.__._..
fZ4 Test Pit No. 2................minutes per inch Depth of Test Pit_...__._______.__.._ Depth to ground water_______________________.
.............e...
-----------------------------------................ .....--------------------------------*------- ...
0 Description of Sbil......0. 3�..... ....5-. 01A...Z5 ....C_(MU ..............
........................................................................................................................................................................................................
U
W
.......................................................................................................................................................................................................
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
........................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'T'Y_E 5 of the State Sanitary Code—The undersigned furtlnjagrees not pi the system
operation until a Certificate of Compliance has been issued by the boar ?f health
Signed--.-....... .......... ............ . ......... . ... .... . .. ...............
Application Approved By... .. .. ........ .....
pp .. .......... ... .... .. ..... ... ....... ........... ..............
Da e
Application Disapproved for the following reason ..............................................................................................................
Date
Permit ......... IssuedL.......................................................
Date
No.....
THE COMMONWEALTH OF MASSACIHUSETTS
BOARD OF HEALTH
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............................
Appliration for Uiupuii al Works Tonuiratrtion Prrutit
Application is hereby made for a Permit to Construct (,W ) .or Repair ( ) an Individual Sewage Disposal
System at
°f ••--
................ ........................................ .....................................................
Location ddress or Lot No
4' Owner j) Address
'_--•----.................................................
. 1, '> !t ..................................................
Installer v Address
dType of Building . .- N Size Lot____ .......................sSq. feet�'+ Dwelling—No. of Bedrooms._____ __________"._-_________..Expans>on Attic ( Garbage Grinder
`4 Other—T e of Building ' ``�' No. of persons Showers `0
Ql YP g -= --------- P ----------------------- ("�) Cafeteria (�..�)
04
Other fix res ' c.....................................___----------------------------------------- -----------------------
t�
W Design Flow______ _________ :._____ ...........gallons per person per day. Total daily flow......... ��?.......................galleons.
9 Septic Tank—Liquid capacity'.::___.gallons Length.la........ Width......0...... Diameter________________ Depth__.Z.'._____..__.
Disposal Trench—No. ..��.��'�=____ idth.................... Total Length.................... Total leaching area___________________sq. ft.
Seepage Pit No-_----------------- Diameter___.__._._..-____._. Depth below inlet_...___._........... Total leaching area___._.___._:_____.sq. ft.
Z Other. Distribution box (,-/) Dosin tank ( ) ; a
Percolation Test Results Performed b - s''f :'�-... Date.._ _y __... ._.... i
a Test Pit No. 1: _ _.....minutes per inch Depth of Test Pit... Depth to ground water........................
44 Test Pit No. 2.................minutes per. inch Depth of Test Pit.................... Depth to ground water........................
._..- e
O Description of Soil .. 4 ±�ti°'.. `� - 1"T�
V ------------------------------------•----------------•--------------------------------•••----------------•------•---•-------••-----•-•-----------•-------••-------•--------••---••••---•-----------------
W -----•------•----=------------------------------------------------•--------------------••-•-----------•--------------------------•--------•---------------------•----------------------------------••••-
V Nature of Repairs or Alterations—Answer when applicable________________________________________________________________________________
-•--------------------------•------------------------------•---•--•----------------...............-----.......------------------------------------------------------------------------...._._.._...•---
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal Syste in accordance with
the provisions of TILT LE 5.of the State Sanitary Code— The undersigned furtive grees not t laclohe syste
operation until a Certificate of Compliance has been issued by the board, f health. -
Signed...........'�" _'�•�-�-°►Zc .-_��-•--� - ---•---••--•----••---- •-•-�--d ...-'�!
``
Application Approved By______ ____ .._.
Da e
Application Disapproved for the following reason ________________•______-•____________________________________________________________._____._ . ._........_.._
...................................... -•-•r •---- _...__.._.
Dat e
..........
/
PermitNo..._.•-•!.. /,!-• ......................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
% BOARD OF HEALTH
....... .. :...............OF.... µ-°e�'-� .................................................................................................
Tatifiratr of ToutpliFanrle
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ) or Repaired ( }
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Insttaller
at.......°'`� . .---•1 __ :1 t cc t -•-------� . -----
--
has been installed in accordance with the provisions of T' -1 5 of e State Sanitary Code a c e 'b in the
application for Disposal Works Construction Permit No._�(� �__'�_���__.____.___ d. _� __.___ _______________
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE AT YHE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE .. Inspector - ---•-•-----•-----------------------------•-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH ]
2y.
! ........!! `'.............OF..-. G .._...___.-..._.__..__....._...___.....___.._._-.___....... / ...�
No... ...•//• FEE. 4
Diuvoua1 Works Tyw�aatutrur#uan-t, rrmft
Permission is hereby granted....._.__ _. __1__ :: .......................................
to Construct (} or Repair ( an Individual emle Disposal System ,
at iV'o.. .&.�h — 3 __..dcr.0 -....:f-�.� ..t!
Street /
as shown on the application for Disposal Works Construction Permit No0 ../
_____ ! Dated_�,.�' F7.________...
..................................
• ---�od-•3.:./------------------•----------..._
°rogR; l ' /^, r �ej of Health r..
Rom'.-yye;
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS t
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