The URL can be used to link to this page

Home My WebLink About0034 WHITE MOSS DRIVE - Health 34 White., Dci\It� I A= ,1 I �1 1 i li it I il'II df1� Y UPC 12934 e be 2.1v3� 3 TOWN OF BARNSTABLE LOCATION (_p+ QV yflde-S, 21, SEWAGE # 4SG 19 VILLAGE tMd S- w- W`l'to 5 ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. '�• fls;SLd1� 7-7 1,3 b I b SEPTIC TANK CAPACITY 000 �n lla%l 5 00 lt��► LEACHING FACILITY:(type) 6xcA^ ,�'T (size) �°` S NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER I� BUILDER OR OWNER Cs �� .Le °' CCU DATE PERMIT ISSUED: (( f I (ra DATE .COMPLIANCE ISSUED: e" --`$ VARIANCE GRANTED: Yes No / � �� :�� 3 � �� `� .. Mop „ .,��:• ��. -,. <.::: �} 'ARCEI. NO. I 0 � 0� No..:. �.... ..q� rFw :............_............. �.y THEALTH�OFUACSSACHTSETT S Bo A R® F o 1-0 O. ................ Appliratiou for Diipuiial Workii Toutitrurtiou Vantit .Application is hereby made for a Permit to Construct (L--y"or Re air ( ) an Individual Sewage Disposal S t t .:�J � _ � .�4..........-•.•.•.......•.- .._ � ........................ Location-A r ss or I of No. �e�� &.11:C.,f' ., doh e® �e� ..e �1 ��' Owner // �._ Address ,S--•---- 1 ?`(.......--••----------------------- ----------5�'1'l--2..-•----.........---•-•---------•----------•----•------...---... Installer Address of Building Size Lo ..__ ______ . d Types g ��_�� ___._Sq. feet U Dwelling—No. of Bedrooms.................: ................ .Expansion Attic 116 Garbage Grinder .M aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther ftu s --------------- ------•--------••-•--•----•-----•••••--••--•--•--••-•-----•----•-•------•-••••--••-_.....--•--- W Design Flow.......5................................gallons per person per day. Total daily flow.........J� ..................gallons. 9 Septic Tank—Liquid capacityLgallons Length................ Width................ Diameter---------------- Depth................ Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No._-_______-_-.-__.- Diameter____________________ Depth below inlet.................... Total leaching ar ................sq. it. Z Other Distribution box ( ) Dosin tank ( ) '. '—' Percolation Test Results Performed byf� � f� i.._C.�'1f/.l��tt te. ..._._ __ ............... ,tea Test Pit No. 1 �-----minutes per inch D of Test Pit.-•-t- -- `—Depth ground water-_-- (i Test Pit No_ _X;; minutes per inch Depth of Test Pit.../�� ----.. Depth to ground water._ ............ - •. . -----------------------•-••......................................................... � � yam'--------;;EA.----- - Description of Soil... _. � !. �! _....___...- V �f_ -------- -�A�-- -------•--------•--------------•---•-------•--•---------------------•------•----------------------------------------------- C U Nature of Repairs or Alterations—Answer when applicable._____________________________•-_--.-_--____________-___-----__---_-----__---___------------___. -------------------------------------------------------------------------------------------------------------------------------------------•---•-------•---------------------------------------.....-•-- Ag-eement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of ii 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the boa of health. Signed...... ,. .•---- ------.. / .....-• ...-•------•----•-•--•. ...... . .......... �{ t Application Approved By-••••-••--•---••--••-••......-- Date Application Disapproved for the following reasons:-----••--------•---•---------------••---...------------•-----••----•-----------... ......................... -•-----•-•-----•••-----------•---•-•-----•----•••...---•-•-••••--•---••------------------•••••--•-------.._.......-----------•----•-•-•-••-•-••--•••-------•-•-•---•-•-•---••-••--•--•-••----•.....---•-- �� s ��.�-d•— Datc Permit No...................................••..... .... Issued. •... Date ......................... . THE COMMONWEALTH OF MASSACHUSETTS I BOARD,,PF HE� 01 0 F.... ............................. Appliration for Mipviial Works Tomitrurtion rumit Application is hereby made for a Permit to Construct or Re air air an Individual Sewage Disposal Syst t • I I 1 11 " ...................... .5... ....k 5 -A A AzK :�t I Location-A ,,,s No ;:i--------- ------------- .................. ......................... ............... ... ......... Owner Address ,j o . .................. ..................................................................... .................................. ........ ...< Installer Address PQ e Size LR-2. (1 Type of Building S .6 2 ......Sq. feet U ------------- Dwelling—No. of Bedrooms--------;-_3............................Expansion Attic) Garbage Grinder,- 0 P4 Other—Type of Building ............................ No. of persons._...__.........._.......... Showers Cafeteria 04 Other fix es ................................................................................................................... ...... Design Flow......4..................................gallons per person per day. Total daily flow.__..... 1:4 Septic Tank—Liquid capacittfiPp.gallons Length................ Width................ Diameter___--.__--__-_ Depth................ Disposal Trench= No..................... Width.................... Total Length.._..........._..... Total leaching area....................sq. f t. Seepage Pit No----------- --------- Diameter....__...__...__.... Depth below inlet................_._. Total leaching area.....; -------*sq. ft. z Other Distribution box ( ) Dosing tank ( ) 0, 14 Percolation Test Results Performed by/ d- te. ................ Test Pit No. ..._.minutes per inch De of Test Pit.................. ground water--_____.____________ -_. (s, Test Pit No__- _minutes per inch Depth of Test Pit.................... Depth to ground water.._......_.........._... .....7 . !-------�V------1---------- ........*------------------------------- ............... ----------------------- ---- --------f 0 Description of Soil..�� .9 I-,)t^h:.1. C e�L: . ............................................................................................... ................................ at L, U --- ----------*---------------------------I--------------------------------------------------------I-------------------**-------- ......................... ----------------------- ..............f........... ..................................................................................................... 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 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health Signed....... ............ ....... .. .. ......................................... A. ......... Application Approved By.................................P.. ............. --- Date Application Disapproved for the following reasons:.............................................................................................................. ........................................................................................................................................................................................................ Date PermitNo....... ..................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..............OF.... ...... .......................... OpWrtifiratr of Tompliatta THIS IS TO CEZTIFY Tha the Individual Sewage Disposal System constructed C-,4-or Repaired I ly....: �1................... 1......:A- ;"r------------------------------------------------------------------- aller at................................................ ........ ...................................... ............A.m�........................................................................ has been instilled--in accordance with the provisions of Ti TIE 5 of The State Sanitary Code s de ., d in the Permit No..akt_J1 __j.cribe application for Disposal Works Construction ... ...-IN,.............. dated-----_4_I.7� ---b--c.......... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE..... '? ................................ Inspector...._0% ..... ------ ------------------------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH • ............OF..... ........................... ................ FEE._.....7 ................. oispao Vork on n f ermi# Permission is hereby granted.... ...................................................................... to Co ruct"YL, or air an InA-u4LISO&,age Di fijstem .at I.............. ............ ............ ---------------------------------------------------------------------- Street 96- 1 4� as shown on the application for Disposal.7Works'Construction Permit No..........1..1....A D ated....... ..................... .................................... ---------------------------------------------------------- Board of Health DATE............IJ.. .. ......................................... FORM 1255 H013 INC.. PUBLISHERS RF- 1SD ' FRO�J 7,-4 Gr F- -k,4--ZL)m E.O Lo7 �� -,-��u Rey `f.� • C.d/us•-grL pgv'flop cv,.�`' 10 L o - � 4 y -� S 7' t y / o I �6,7�y 1 l33 a�o s �✓e r r I 1. I CERTIFY THAT THE PROPOSED BUILDING SHOWN ON THIS PLAN CONFORMS TO THE ZONING LAWS OF c3 gRAISTA8z-r= , MA. LEGEND DATE: r EXISTING SPOT ELEVATION 0 PROPOSED SPOT ELEVATION •`'::' ` ' �. 'gNoc EXISTING CONTOUR ---0- -- <> s PROPOSED CONTOUR 0 "` °� PAUL A. v+ %: UAUID P. S:i'; <" MARIANO :;:, o LEVY NOTE., THE LOCATION OF ANY UNDERGROUND u 4;. No. 10617 SEWERAGE,WELLS, OR OTHER UTILITIES SHOWN ON clvl� �\� THIS PLAN IS APPROXIMATE ONLY AS DETERMINED Cx no.3111,r� - FROM c � t d da , b FROM RECORDS AND/OR. VERBAL INFORMATION. "4 ',r , � ?THE CONTRACTOR IS RESPONSIBLE FOR THE � q�; VERIFICATION OF THE EXISTING LOCATIONS IN THE FIELD. RE I TERED ENdINEEFrTR AD . LEVY 8c ELDREDGE ASSOCIATES,INC. PROPOSED PLOT PLAN't CLIENT�RE dpap. pp 4 ENGINES-RS- LANDSCAPE ARCHITECTS JOB NO. Wil SOT .3 T,E_ M055 Z)gi PLANNERS - LAND SURVEYORS """' DR: BY I N• 889 WEST MAIN STREET CHKD.BY: Aa a s-cA13 L �.. x. CENTERVILLE, MA. 02632 SHEET-L...OF 2 SCALE,.L: .=?�'_. DATE_ N07E /F E/TNER 7-Ne SEPT/C TANf- OR �r 20 FT. am ZeACN/NG R/T ARE MORE 7-NA-IV /2"BELOPV• /D FT M/� 4"O/A9. GRArDE, A 24"O/AMETER C'ONCRE7'*=- .COMER ScyEou[.E 40 St/ALL BF BRDUGNT TO 6/rAOE.�AN ,Eit'TRA C0NCi7E7•E PY.C. P/po H F,4VY CA 57- /ROVv cOYER S/1,1LL_ a,= USED [06•S coERS Al/N. P/TCAl /F-//V DR/VEyVAY a,. �B PFR F7 a _ o OE CO VEfz CL EAN .SANG A BAC.ICF/L.L 1, D ' . *LAYER I/q ~' MIN.P17CN D/ST. " WAgHEO S3?�NE ..:•,: /4-pEX�: SEPT/C TANK A I I • • • 1 6 • '. BOX • 1 � ► • • • • � Dept+ i p EFFECT•/VE e • � ��.cw� GL�+.�{ • a • • DEPTH o • 1 ' v • WA5h+E0 STONE �Q; _ a. 0 1 1 • • • • • • 1 �p o • ;.: x 2•• -2-7•S G RD a• 1 1 a - ,op o RECAST P SEEPAGE )13 x/,0 = /13•p UP/� a a" • • • e e • • • • poop �1 c 4�0, � >1 e o • • • • I • • 1 1 A D P/7 L7/� �-�pu/✓. //N✓�"R'T EL E✓�8T/ON S 5 G!�D /NY,,-A7- AT EU/LD/NG /O/ •80 FT 6 FT. O/AM. /NL ET SEPT/C T'4NK /at .Go FT. F7 O/�?!►9• C(SEE T�UL.4T)0N� O4171-ET,SERT/C 7A NK /OI •4-0 Fr /N,S,ET D 9l/57,T mom BOX/b/ •20 FT. SECT/ON OF CsRDuNp / ITEM° TASLE ou LE'7-.w5-r ,.aar!ON boX lol,o o x7 .5��4✓AC�� /aS,�t S's4.L. SY..�T' M IA14ET LEACH/NG Fd/T /40, ?v Fr. 7A8411-ATJCN LEACH//VG p/7' D/MENS/ON A 3 FT. D,FSJG/el CRlTER/A sCAL� %" _ / -O� D/�°ILoN.r/oN � �'T• NUMaER Olc 6E®Ro4M5 3 D/MENS/ON C �. G4.40AGE A/SPO.SAZ- UNIT NOAJF SOIL L.OG S®/L 'VEST T07A4 ESTlMATEb FL.o`v 330 G,41-1DAY SOIL TEST SOIL 74I=S7-#2 NCJMBER of 4erACNINT P/TS FtEY. U� $', ELAFY' DATE s7F SOIL TEST S/OE LJEACHIMC, PER'P/•T S,1/ FT. RESfJLTS wlTNESSED BY 70A, 14c,'- ^1 O�-Z.' TOPSo/G .00TYom L.4y4cH//VG PER PIr LL, PT,. c 5u6 %`- f',dF#V �4T/ON AArar.•I -Z MIIV�I/NCH TOTAL LEACH/NG AREA 2(44 Sq. Fr. ; .a��APEIrcoLArioN RATE 2 M/N.�/NCH RESERVE LEA4rNlNC.4REA�4 _SQ. FT. f- C�A� Ali / DAVID pp',• • �rQ A'1ARIANO SAti1D :3:c- CIVIL P" !s h'a 31115 LOT 3 A)///TF MOSS PRI VS LEVY & ELDREDGE ASSOCIATES. INC. EL. 9�• 8 889 WEST MAIN STREET CENTERVILLE,MASSACHUSETTS 0263E �•'NO GiQOlJND Y1G4TER E/VCOC/NTL�RED CL/ENT: � � � OATS=/� S�BIo C GI1t0UAID kV�47 t? AT =Z- - .JOB /VD. 103 SHE,ET2 OF 2 \ COMMONWEALTH OF 1VIASSACHUSETTS A.1 t' EXECUTIVE OFFICE OF ENVIRONMENTAL.AFFAIRS. DEPARTMENT OF ENVIRONMENTAL PROTECTION ti< t .W Sy TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR YOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM` PART A CERTIFICATION Property Address: WAid ZVALVWQ Owner's Name: Owner's Address' CEll� ._�F Date of Inspection: 3�/6�/D I RE p Name of Inspector: please riot) t'f ,� pf�0�0` Company Name: 9 ' MAR 1 9 2001 Mailing Address: z . TOWN OF 6ARNSTABLE 1c��fDy� HEALTH DEPT. Telephone Number: jgo t• ?1 R- 2 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 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 C itionally Passes ds F her Evaluation by the Local Approving.Authority • � ails Inspector'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..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 6/15/20.00 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGV,DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date t of Inspection: / Inspection Summary: Check A,B,C;D or E/ALWAYS complete all of Section D A. ystem 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 sectiowneed to be replaced'or, repaired.The system,upon completion of the replacement or repair;as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N;ND)in the for the following statements: If"not determined"please explain. 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 inirninent 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 obstructedpipe(s)or due io-a broken settled or uneven distribut ion . .. box. System will pass inspection if(with approval of Board of Health)_: broken pipe(s)are replaced obstruction is removed distribution box`is leveled or replaced ND explain: .The system required pumping more than'4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 I . Page 3 of I I. OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEKINSPECTION FORM PART.A CERTIFICATION(continued) Property Address: L��U14aZ:rrxa �/.�3 Mo4. ' Owner: 1 Date of Inspection: 3 /S 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.' 'Sys'tem will'pass,;uniess'Board of Health.determiiiesi'if'accoidance with 310 CIViLR 5i303(1)(b)that the system is not functioning in a.m.anner which will protect.public health,safety and the.env iron ment: _ Cesspool or privy is within 50 feet of.a surface water. T 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 proiects.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 501,feet or more from_as 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 weii.is free from pollution from that faciiiiy and . the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided.that no other failure criteria are:triggered. A copy of the.analysis must be attached to this form.. 3. Other.: 3 Page•4 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTI+JM INSPECTION FORM `:PART A CERTIFICATION"(continued) Property Address: ' (mot/ Owner: Date of Inspection V 21. 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 II clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool V Liquid depth in cesspool is less than 6"below invert or available volume is less than''/z day flow Required.pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the 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 ofa.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 coliform bacteria and volatile organic compounds indicates thatthe well is free from pollution from that facility-and the presence:of ammonia nitrogen.and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310£MR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correctthe failure. E. 'Large Systems: To be considered a large system thesystem mustserve a:facility-with a design flow of10 000 gpdto 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 II of public water supply well If you have answered"yes"to any questibn 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 ownershould contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY_ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: P arm A. . Owner: Date of In pection Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No v_ Pumping information was.provided by:the owner,occupant,or Board of Health . _ _jZ Were.any of the system components pumped out in the previous two weeks? _1Z _ Has the system received normal flows.in the previous two week period? Have large.volumes of water been introduced to the system decently or as part of this inspection? J — 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 ofsewageback.up? ✓ _ Was the site inspected for signs of break out V _ Were all system components,excluding the SAS, located on site? _V _ 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? _jZ_ Was.the facility owner(and occupants,.ifdifferent 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 Existing information. For example,a plan.at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue.approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] Page 6 of 11 .OFFICIAL-INSPECTION,FORM—NOT FOR,-VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE`DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:2- lf) ,{,&p 192kq Owner: !u19 Date of Inspectio : FLOW CONDITIONS RESIDENTIAL k" Number of bedroom's(:design): . Number of.bedrooms(actual):...: DESIGN flow based on 3 10:CMR 15.203 (for example: 1]0 gpd x#of bedrooms):�d Number of current residents:�_ Does residence have a garbage grinder(yes or no);/ 7 Is laundry on a separate sewage system.(yes or`no�;(if yes separate inspection required] Laundry system inspected(yes or no):/-2W- Seasonal use:(yes or no.):Z20-. . Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no);,�Zr Last date of occupancy:ay" me, COMMERCIAL/INDUSTRIAL066- 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 pirt of the inspection(yes or no). If yes, volume pumped: gallons--How was guantrty 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): Ap roximate age of all components,date installed(if known)and source of information': Were sewage odors detected when arriving at the site(yes or no): . 6 II -- Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR.VOLUNTARY_ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART C SYSTEM.INFORMATION(continued) Property Address � y . d(?,4 Owner: Date of Inspection. /��r, BUILDING SEWER.(locate on site plan)/X/0- 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:-Zlocate on site plan) Depth below grade: /07 Material of construction:_✓concrete_metal_fiberglass__yolyethylene —other(explain). If tank is metal list age:,— Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: S 1((o k Sludge depth: Distance from top of sludge to bottom of.outlet tee.or baffle: ,`7� . 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:T How were dimensions determined: �j � p� Comments(on pumping recommeiFdatione, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.)• 7" 2/I u ai-� GREASE TRAP/ ocate 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.): 7 Page 8 of 11 OFFICIAL INSPECTION'.FORM-NOT FOR:VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM`INFORMATION(continued) Property Address: 3 7 IP66az Owner: Date of Inspection:,/ TIGHT or HOLDING TANK:,ZhIl -(tank must'bepumped at time of inspection)(locate on.site plan) Depth below grade: Material of construction: concrete metal__fiberglass _polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping- Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: if resent must be'open ed locate on site pl an) ( P )( P ) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of kage 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;): 8 r Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM;INFORMATION(continued) Property Address: `0 c� Owner: 121 Co y Date of In pection SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located explain why: Ty P e . .....__..... ✓leaching pits,number: 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.): - . u g � CESSPOOLS/'A-(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%/,Yj-H- -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.): 9 Page 10 of 1 l OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE'DISPOSAL'SYSTEM:INSPECTION FORM `PART.0 SYSTEM INFORMATION(continued) Property Address: 3g62 "A Owner: Date of lnspection: In I -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. 6vv r J 1 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ? Owner: Date of Inspection:��i Ez/(,Z 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: l C I1