HomeMy WebLinkAbout0071 WATERSHED WAY - Health 71 WATERSHED WAY, '
, grsZo n s In ,,
s
r COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET,,BOSTON MA 02108 (617)292-5500
yJ y
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B. STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
1►a CERTIFICATION /� A
Property Address: 7 f W/f-P2 4 5�j gC� '�: oq Name of Owner &f L AA�L d
r Address of Owner 2
Date of Inspection: T, 2
Name of Inspector:(Please Print)
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: !vl CaQ 1 441 '5e jg,K c`9 i ca«+,1..
Mating Address: "1 5. % r�-!� �r/� 4 :'
Telephone Number:
CERTIFICATION STATEMENT
1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on.my training and experience in the proper function and.
maintenance of on-site sewage disposal systems. The system:
gasses
Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
— Fai s
Inspector's Signature: rliG..N� Date:
The System Inspector shal submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)•days of
completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department ofrEnvironmentai Protection. The original should'be sent to-Vm
system owner-and copies sent to the buyer,if applicable, and the approving authority.
NOTES AND COMMENTS
RECEIVED
APR 2 5 2001
TOWN OF BARNSTABLE
HEALTH DEPT.
revised 9/2/98 Page Iof11
4
_ M
i�! Printed on Recycled Paper
AW
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: UJ4 4,e,=Sh ed:� Uhf�' Al l ��
Owner: n e z P/--4-4`7
Date of Inspection:
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
&�l have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 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.
Indicate yes,no, or not det re m'ihed(Y,N, or ND). Describe basis of determination in all instances. If "not determined",explain why not.
The septic tank is`metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)-indicating that the tank was installed within twenty(20)years orto a date of the inspection;or
the septic tank, whetherNo�not metal,is cracked,structurally unsound, show stt6 tantial infiltration or exfiltration, or tank
failure is imminent. The sys m will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Heat..
_ Sewage backup or breakout or high static ater level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distrib n box. The system will pass inspection if(with approval of the Board of
:Health).
,bro an pipe(s)are replaced
. obstruction is removed
distribution box is levelled or replaced
- e system required pumping-more than fourtimes-ayear•due to broken•or obstructed pipe(s). The-system wilt-
peas-inspection if(with approval of the Board of Health): ---
broken pipe(s)are replaced
obstruction is removed
revised 9/2/98 Page 2of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A'
CERTIFICATION(continued)
Property Address:
Owner:
Date of Inspection:
C. FURTHER EVALUATION IS REQU}RED BY THE BOARD OF HEALTH: ,
Conditions exist which requira�%ther evaluation by the Board of Health in order to determine if se ystem is failing to protect the
public health, safety and the envi onment.
1) SYSTEM WILL PASS UNLESS BOARROF HEALTH DETERMINES IN ACCORDANC 310 CMR 15.303(1)(b)THAT THE SYSTEM
IS NOT FUNCTIONING IN A MANNER ICH.WILL.PRQTECT THE PUBLIC H AND SAFETY AND-THE ENVIBONMEN.T:
Cesspool or privy is within 50 fe t-of surface water
_ Cesspool or privy is within 50 feet of a bordering vegetate etland or a salt marsh.
4
2) SYSTEM WILL FAIL UNLESS THEfBOARD OF HEALTH(AND P LIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER T PROTECTS THE PUBLIC HEA TH AND SAFETY AND THE ENVIRONMENT:
The system has septic tank and soil absorption system(S S)and the SAS is within 100 feet of a surface water supply or
tributary to a s rface water supply.
The syste2 as a septic tank and soil absorption system and t SAS is within a Zone I of a public water supply well.
Th/ewater
(�has a septic tank and soil absorption system and the AS is within 50 feet of a private water supply well.
Tham has a septic tank and soil absorption system and the S S is less than 100 feet but.50 feet or more from a
pri supply well,unless a well water analysis for coliform b cteria and volatile organic compounds indicates that the
wee from pollution from that facility and the presence of ammnia nitrogen and nitrate nitrogen is equal to or less
►lean 5 ppm. Method used to determine distance (approx'urr"on not valid).
3) OTHE \\�
revised 9/2/98 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner:
Date of Inspection:
D. SYSTEM FAILS:
You must indicate either "Yes" or No to each of the following:
I have determined that,one or more of the following failure conditions exist as described in 310 CMR 15.303, The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No \
Backup of-sewage I fecili"r-s"tern+componentdaet.toen overloaded or ciegged-SA&or,cesspeol. ---T—=
1'
Discharge or ponding f effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the d tribution box above outlet invert due an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is ess than 6" below invert ;OT
av lable volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorpti n System, sspool or privy is below the high groundwater elevation. -
Any portion of a cesspool or privy's w' in 100 feet of a surface water supply or tributary to a surface water supply:
Any portion of a cesspool or priv s- ithin a Zone I of a public well.
Any portion of a cesspool or rivy is wit in 50 feet of a private water supply well.
Any portion of a cesspo I or privy is less-th n 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the we has been analyzed to be acceptable, attach copy of well water analysis for
-coliform bacteria,volatile organic�compounds, mmonia nitrogen-and nitrate nitrogen. -
E. LARGE SYSTEM FAILS:
You must indicate either "Yes' or "No" to each of the following:
The following criitt is apply to large systems in addition to the criteria above:
The system selves a facility with a design flow of 10,000 gpd ors greater(Large System)and the system is a significant threat to public
health and s6ety and the environment because one or more of the\following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system-is-within-200 feet--of a tfibutary4ea-surfeae drinking-water-suppi r-.....
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 upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
•
revised 9/2/98 Page 4or11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
` CHECKLIST
Pr Address: Lo
Owner:
Date of Inspection:
Check if the following have been done:You must indicate either "Yes" or"No" as to each of the following:
Yes No
_ Pumping information was provided by the owner,occupant,or Board of Health.
-None of the systemxompoaents-hausJmn punped4=.atJeast"tawo weeks aa&the-system has*aeumeceiaingilenow flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
L"." The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
All system components,excluding the Soil Absorption System, have been located on the site.
✓� _ The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System orrthe site_has been determined based on:-- -
_t� _ Existing information.For example, Plan at B.O.H.
Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
[15.302(3)(b)]
2/
The facility owner_Und_occupants..if different.from-ownerLwars prauided;with.bAwmatiowon.tha4umper niWntena2rm-f
SubSurface Disposal Systems.
revised 9/2/.98 Page 5of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: `.cJ-e7 v^ ,/4j'-,eDy Owner: �® "
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: ?36' g.p.d./bedroom.
Number of bedrooms(design):_'. Number of bedrooms(actual):_
Total DESIGN flow .73v
Number of current residents:_L
Garbage grinder(yes or no):_ v
Laundry(separate system) (yes or✓no): 7If yes,separate.inspection:required
Laundry system inspected (yes or no)
Seasonal use(yes or no):�'1�
Water meter readings,if available(last two year's usage(gpd): 000
Sump Pump(yes or no): Nv
Last date of occupancy: o^
COMMERCIAUINDUSTRIAL:
Type of establishment:
Design flow: gpd ( Based on 15.203►
Q Basis of design flow
{Grease trap presen •. r no)_
Industrial Waste Holding Tank p eqx (yes or no)_
Non-sanitary waste discharged to the Tit a tem:(yes or no)_`----"`--�y
Water meter readings,if available:
Last date of occupancy: 4
i
OTHER:(Describe)
Last date of occupy t
GENERAL INFORMATION
PUMPING RECORDS and source of information:
c7t:C>'� f- a d j/>Ua,1_. - /U� �t.�I
System pumped as part of inspection: (yes or no)IVO
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF STEM
L/Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared sys me (yes or no) (if yes,attach previous inspection records,if any)
1/A Technologyjetc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed{if known)-end source of,information:
Sewage odors detected whewarriving at the site: (yes or no)1l.Cv
revised 9/2/98 Page 6of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: Lo r t? tv
Owner: M
Date of Inspection: ^ lS s
BUILDING SEWER:
(Locate on site plan)
Depth belo rade:_
Material of constru _cast iron 40 P _other(explain)
Distance �privatewa well or suction lineDiameter
Commenting,evidence of#eakage,-etc.)
SEPTIC TANK:_
(locate on site plan)
Depth below grade:
Material of construction: n rete_metal_Fiberglass _Polyethylene_other(explain)
/n �a.i
If tank.is(natal,list age_ ls:age-confu�ied by Cert' cate of Compliance_(Yes/No),
Dimensions: 1?1>�- X
Sludge depth: 1Z
Distance from top of sludge to bottom of outlet tee-orbaffle:
Scum thickness: 7 A �l
Distance from top of scum to top of outlet tee or baffle: A
Distance from bottom of scum to bottom of outlet tee or baffle:_
How dimensions were determined:Sfic:K cXg-b5VRa
Comments:
(recommendation for pumping, condition of inlet and outlet tees or-baffles,depth pf liquid level i re l tion to outlet invert,structurat4nteg ity,
evidence of leakage, et ) 4--
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction: oncrete_metal_Fiberglass _Polyethylene_other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or be
Distance from bottom of scum to bottom of ee or be
Date of last pumping:
Comments:
(recommendation for mping, condition of inlet,and outlet tees or baffles,depth of liquid in relation to outlet invert, structural integrity,
evidence of leak e,etc.)
revised 9/2/98 Page 7of11
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: [ I (j1
Owner:
Date of Inspection:
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below g de:_
Material of constru n:_concrete_metal_Fiberglass_Polyethylene_other(e n)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm in ing order:Yes_ No_
Date of previous pumping:
Comments:
(condition of inl ee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet invert: 'U
SComments:
(note:if level and istribution is equal,evidenee of solids carryover;evidence of leaks a into or out of Pox, etc.) Cr ._.it.��._-
PUMP CHAMBER:_
(locate on site plan)
Pumps in working order:(Yes or o
Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber,condif �ump, nd appurtenances,
revised 9/2/98 Page 8of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(confined)
Property Address:
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS):_
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
Type:
leaching pits, number: (C) L—
leaching chambers,number.:_
leaching galleries,number:_
leaching trenches,number,length:
leaching fields,number, dimensions:
overflow cesspool,number:_
Alternative system:
Name of Technology:
Comments:
(note condition of Soil, signs of hydr ulic failure level of ponding, damp soil, ond' 'on of vegetation, etc.)
CESSPOOLS:_
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer;
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow(cesspool must be pump as part of inspection)
4
Comments:
(notecondition of soil, signs of hydraulic f ire,level of: ing, condition of,vegetation, etc.)
PRIVY:_
(locate on site plan)
Materials of const ction: Dimensions: _
Depth of solids
CommentViion
(note con of soil,signs of hydraulic failure,level of ponding, condition of vegetatioXe .)
revised 9/2/98 Page 9of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
J� /� S
Property Address: (`
Owner: M
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
6
4 -c
j3-c -
p cL - a
revised 9/2/98 Page 10of11
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
r Property Address: ��o��,,/
Owner: c*,y
Date of Insp� /
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water fit.e7
Check Cellar A.1
Shallow wells
Estimated Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
L--"O'bserved.Site(Abutting property,observation hole, basement sump etc.) j
Determined from local conditions
Checked with local Board of health ,
Checked FEMA Maps
L---ehecked pumping records
Checked local excavators,installers .
'--'Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
o e
0
e
revised 9/2/98 Page 11of11
+ 0
Commorweatth of Mosmchusetts , John Grad
Executive Office of ErMrommintOi Affdrs D.E.P. Title V Septic hnspector
Department of P.O. Box D Environmental Protection Teaticket, MAA 0 0 2
(508 3 3
9
o s 9 do
0 0o� `0
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM A
PART A hcvvo Vol
CERTIFICATION �
SUN 11 1997
Property address: 71 Watershed Way Marstons Mills Address of Owner: TOWNOF N
Date of Inspection:e/9197 (If different) HEA(H pEprABLE
Name of Inspector:JohnGracl Calderaro
Company Name,Address and Telephone Number: A
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
X Passes This inspection Is based on criteria defined in Title V
_ Condition ly P sses code 310 CMR 15.303.My findings are of how the system is
_ Needs F h Evaluation B the Local Approving Authority performing at the time of the Inspection.My Inspection does
y PP 9 ty not Imply any warranty or guarantee of the longevity of the
F2ils septic system and any of its components useful life.
Inspector's Signature: t' Date: 619197
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B,C,or D:
A] SYSTEM PASSES:
x I have not found any information which indicates that the system violates any of the failure criteria
defined as 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 completion
of the replacement or repair,passes inspection.
Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined",explain why not.)
The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved
by the Board of Health.
(revised 11/15195)
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500
1
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 71 Watershed Way Marstons Mills
Owner: Calderaro
Date of Inspection:619197
_ Sewage backup or breakout or high static water level observed in the distribution box is due to a broken,
settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
_The system required pumping more than four times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
_ Conditions exist which require further evaluation by the Board of Health in order to determine if the
system is failing to protect the public health, safety and the environment.
1} SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 of a public water
supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water
supply well.
_ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private
water supply well,unless a well water analysis for coliform bacteria volatile organic compounds indicates that the well is
free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm.
3) OTHER
D] SYSTEM FAILS:
_ I have determined that the system violates one or more of the following failure criteria as defined in
310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be
contacted to determine what will be necessary to correct the failure.
Backup of sewage in facility or system component due to an overloaded or clogged SAS or
cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
cesspool.
SAS is in hydraulic failure.
(revised 11115195)
2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 71 Watershed Way Marstons Mills
Owner: Calderaro
Date of Inspection:619197
D]SYSTEM FAILS(continued)
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6°below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Numbers of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone 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. 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 large systems in addition to the criteria:
_ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area (IWPA)or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further Information.
(revised 11115195)
3
Yl_�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CH ECLIST
Property Address: 71 Watershed Way Marston Mills
Owner: Calderaro
Date of Inspection:619197
Check if the following have been done:
X Pumping information was requested of the owner,occupant,and Board of Health.
X None of the system components have been pumped for at least two weeks and the and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
X As built plans have been obtained and examined. Note if they are not available with NIA.
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout.
X All system components,excluding the Soil Absorption System,have been located on the site.
X The septic tank manholes were uncovered,opened, and the Interior of the septic tank was Inspected
for condition of baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge, depth of scum.
X The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
X The facility owner(and occupams,if different from owner)were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11115195)
4
,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 71 Watershed Way Marston Mills
Owner: Calderaro
Date of Inspection:619197
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 440 gallons
Number of bedrooms: 4
Number of current residents: 4
Garbage grinder(yes or no): Yes
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings,if available: nla
Last date of occupancy: rda
COMMERCIAL/INDUSTRIAL:
Type of establishment: nla
Design flow:9 gallons/day
Grease trap present:(yes or no) No
Industrial Waste Holding Tank present:(yes or no) No
Non-sanitary waste discharged to the Title 5 system:(yes or no) No
Water meter readings,if available: n►a
Last date of occupancy: Na
OTHER: (Describe) nla
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System has not been pumped in the last two years.
System pumped as part of inspection: (yes or no)Yes
If yes,volume pumped: 1500 gallons
Reason for pumping: Maintenance.
TYPE OF SYSTEM
x Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) ( if yes,attach previous inspection records,if any)
Other(explain)
APPROXIMATE AGE of all components,date installed(if known)and source information:
9-11-89 Cammett
Sewage odors detected when arriving at the site:(yes or no) No
(revised f 1115195)
5
IV -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 71 Watershed Way Marstons Mills
Owner: Calderaro
Date of Inspection:619197
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 16�
Material of construction:X concreate_metal_FRP_other(explain)
Dimensions: L 8'6'H 5'7"W 4'10•
Sludge depth:5'
Distance from top of sludge to bottom of outlet tee or baffle: 22'
Scum thickness:3'
Distance from top of scum to top of outlet tee or baffle:6'
Distance form bottom of scum to bottom of outlet tee or baffle: 15•
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.)
Septic tank and all components are structurally sound.Recommend pumping system every two years for maintenance.
GREASE TRAP:
(locate on site plan)
Depth below grade: n1a
Material of construction: _concrete_metal_FRP_other(explain)
Dimensions: rda
Scum thickness:n1a
Distance from top of scum to top of outlet tee or baffle:n1a
Distance from bottom of scum to bottom of outlet tee or baffle: n1a
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.)
Na
(revised 11115195)
6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 71 Watershed Way Marstons Mills
Owner: Calderaro
Date of Inspection:619197
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: Na
Material of construction:_concrete_metal_FRP_other(explain)
Dimensions: n1a
Capacity: n1a gallons
Design flow: n1a gallons/day
Alarm level: Na
Comments:
(condition of inlet tee,condition of alarm and float switches, etc.)
Na
DISTRIBUTION BOX: X
(locate on site plan)
Depth of liquid level above outlet invert: Liquid level with bottom of pipe.
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box etc.)
Distribution box Is structurally sound.
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances, etc.)
Na
(revised 11115195)
7
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 71 Watershed Way Marston Mills
Owner: Calderaro
Date of Inspection:619197
SOIL ABSORPTION SYSTEM(SAS):X
(locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
nla
Type:
leaching pits,number: 1,000 gallon leach pit
leaching chambers,number:nfa
leaching galleries,number: nfa
leaching trenches,number,length: nfa
leaching fields,number,dimensions:n►a
overflow cesspool,number:nfa
Comments:(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
The overtiow is structurally sound and functioning properly.lt was 112 full at the time of the inspection.
I
CESSPOOLS:_
(locate on site plan)
Number and configuration: nfa
Depth-top of liquid to inlet invert: nfa
Depth of solids layer: nfa
Depth of scum layer: nfa
Dimensions of cesspool: rda
Materials of construction: nfa
Indication of groundwater: nfa
inflow(cesspool must be pumped as part of inspection)
nla
Comments:(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation,etc.)
nla
PRIVY:_
(locate on site plan)
Materials of construction: nfa Dimensions: nfa
Depth of solids: n►a
Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
nfa
(revised 11115195)
8
' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 71 Watershed Way Marstons Mills
Owner: Calderaro
Date of Inspection:619197
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
(� A
i
Dec
�J
� R A
D
DEPTH TO GROUNDWATER
Depth to groundwater:12 feet
method of determination or approximation:
USGS Maps and Charts
(revised 11115195)
9
�71 TOWN OF BARNSTABI.E ��`059 ✓1
LOCATION SEWAGE # '7G
VILLAGE r� �Ot SY1 LL1�' ASSESSOR'S MAP & LOT 91
INSTALLER'S NAME Sz PHONE O. (��y►�Y1141 �2
'/�
SEPTIC TANK CAPACITY /000
LEACHING FACILITY:(type) i000 9,01/&7,? (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER , w`
BUILDER OR OWNER hn t
DATE PERMIT ISSUED:
DATE COUPLIANCE ISSUED: , -Il-
VARIANCE GRANTED: Yes No
ex
tv
PC L
a
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
�cacvnz....................OF......
•.gir�sT7La�4 E
Applira#iou for Uiopooaal Works Tomitrurtioaa Famit
Application is hereby made for a Permit to Construct (K or Repair ( ) an Individual Sewage Disposal
System at:
4 oT /93
................_................................................................................ ................................•-----._.._._..------•-----------------------...............--•---
Location-Address or Lot No.
..................U0�!s_.4L...I-Ir.......�xniiltl----•---•----•----...._...--._......... ............... l jo—Y--•-------•--•---------------•------------
Owner Address
W .................... ... ............ .......... ---•--�-�--�•�--- --•--•----.. ..........------ a! -� fll.....
Installer Cy�^""'d Address
Type of Building Size Lot____/Zf l ....Sq. feet
U Dwelling—No. of Bedrooms.......exz ......................Expansion Attic WO) Garbage Grinder (A/'c�
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
aOther fixtures .------••---•---•----------------•-•--------•---------•------------•--•--------•••••------......•--•-----.....----•��c�--------•-••------...
g g P P _ oy I-daily . .al
W Design Flow................. .......��_..._gallons per person Per day. Total dail flow...._.______._._____.._____.._ ___._...gallons.
WSeptic Tank—Liquid capacity.IMO.gallons Length.$--_.16..... Width.... 10... Diameter................ Depth..,7_-.1 __.
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No----_o�G------- Diameter.....L0.___.._. Depth below inlet.....&........... Total leaching area. 16�.....sq. ft.
Z Other Distribution box (X) Dosing tank ( )
Percolation Test Results Performed by. :-yl'11,=hnj= ?�� _�_ x r_ _1\1s� ....... Date....6.-%f R. ..............
a Test Pit No. 1----9Z.--------minutes per inch Depth of Test Pit--- ._.. Depth to ground wa _-_CIF ___.
rX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground . ....
O ----•--------- ----------------•-•..._.................----•--------•--••......--•---.._................................
Description of Soil....i43_-4 •, rr r% u�z Qe:/ ---•--------. A�Yr�t.......
(� No`302_G
UNature of Repairs or Alterations—Answer when applicable-------------------------------------------------------------- v�,c :%c �
Agreement
Crd"G 6-17-$'p'
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'TTIE
5 of the State Sanitary Code—'The undersigned further agrees not to place the system in
operati tilYeihca of Compliance has been issued by the board of he th.
r /
Signed. ` .................................
plication Approved By................. f .
Date
Application Disapproved for the following reasons:_.............................................................................................................
--------------------------•-••--------------•------•--......-•----...-----....--•----•--.......---------•---••------------•---•-----•••--------------------•-•---•---•-----------••---------•---••...._.
'" /.�(� Date
Permit No._...___ �•
'4
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
U .._................OF...... .>KnJ r}r
Apli tration for Dhipogal 10orka Tontrurtion rrmit
Application is hereby made for a Permit to Construct (K) or Repair ( ) an Individual Sewage Disposal
System at:
4 o 7-- i 1M
................__.............................................................................. .......-•----------------•--•-----------------......------......----------•----------••----•--....
_ Location-Address or Lot No.
JCl Il 12e ��. 5h11 ':d....................................... 4.d/J y........--................................
Owner
Address
ai..�' � .........6� -----------•---•--•------•- ----•--•--•--•............:.......1y1.�f ...........................................
Installer Address
Type of Building _ Size Lot----�_7�. l _t._..Sq. feet
V Dwelling No. of Bedrooms......./`!'��...._._ /✓1-, g— ...............Expansion Attic (/I/o) Garbage Grinder ( e)
a Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( }
Other fixtures ..
W
Design Flow...............................-!5- -_gallons per person per day. Total daily flow_._........•.__........�'?�......_..gallons.
WSeptic Tank—Liquid*capacity.!()OOgallons Length.)._..�a'' Width__'4,'_!Q Diameter................
x Disposal Trench—No. .................... Width.................... Total Length............._...... Total leaching area....................sq. ft.
Seepage Pit No..... ....... Diameter.....ZQ........ Depth below inlet.....6,-`-......... Total leaching area..5!�4� -----sq. ft.
Z Other Distribution box ()') Dosing tank ( )
aPercolation Test Results Performed by.. ___ e�h n�cwic •_.- zxiTr-_z_•(,1 �.._.... Date___-�-/�... . .............
0.4 Test Pit No. 1....a........minutes per inch Depth of Test Pit... ._.. Depth to ground wat
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground jfa.FR4 --
-----------------------------------------------------------------------------------------------------------•--•--••----
` STLr :1_N G
Description of Soil 'O SvL�o.
--.....L------ -----•--•-------••-•--•--•••--•-••••--• ---•-- ' ......ALtY,1 s j}
---------------------------------------------------------------------------------------------------------------------------------------------------------------• A _y6.Q '
1�1a-3Il21
U Nature of Repairs or Alterations—Answer when applicable.----------------------------------------------------------- .F��S��,F`. '
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with L7-dY
the provisions of:I TALE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operati tti)/ ifica, of Compliance has been issued by the board of health.
-c
Signed....•-•-----=----- --•---....�..---•-----'---... °`-----_ /� _:�.P. .f�._ --....
• �Date� -
plication Approved BY " -• - - ..._....... ....
Date
Application Disapproved for the following reasons .............................................
..............................-•-•--••-•••------•-----•-•-------••-•••••-------••--••-----•--•••---•----•••...._..-•••••-•-•-•---•-------•••------.......•••---•-•---•••--•--••-•...----•-••--••--••--.
�j Date _
PermitNo.........D .-. _26.&-----------•-------. Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�a J...:....r--........O F...: 1....... � .�- .......................
Tntif iratr of Tomplianrr
THIS 1$ TO CERTI That the Inrxwidual Sewage Disposal System constructed ( ) or Repaired ( )
` ......... C
/'
has been installed in accordance with the provisions of TIT 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.........
n.764..... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT TIME
SYSTEM WILL FUNCTION SATISFACTORY.
)1--'�?............................ Inspector..-•-----•-•-
DATE............................. ..... .,-10...................................................
THE COMMONWEALTH OF. MASSACHUSETTS
BOARD OF HEAL H
..........................................OF. �f .................... FEE
NO...��.�.LSY.S�.- FEE........................
Disposal Workii Ton !r ion amit
Permissio;,- )
is reby granted_.._ ....... "'._.__......
•------•-------••.................................••..--...
to Construct or Re ai ( ) an Individual Sewage Disposal Syst y
at No. 'gyp -�--
.. ..............
/,S€reet a
as shown on the application for Disposal Works Construction Permit No.!�7�l�.... Dated......2.� -----/------.�--------
v Board of Health —DATE...... /HOBIBS
ram -- >... ....................................
FORM 1255 & g EN. INC.. PUBLISHERS
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