HomeMy WebLinkAbout0026 WILLIMANTIC DRIVE - Health 26 Willimantic Drive
Marstons Mills P
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TOWN OF BA.RNSTA.BLE
GC,kTION o��o bJt"�V�nY�rry�L ��. SEWAGE #
VjL ,AGE i MMrK i I ASSESSOR'S MAP& LOT ® ®5
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INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY iiRoui W,-&° 1 Sbf i x 6
LEACHING FACILrrY: (type)PIZ (size) kco Tid
NO.OF BEDROOMS
BUILDER OR OWNER LC&IVI,<-C-f--
W!,M 'DATE: COMPLIANCE DATE: Z
Separation Distance Between the: I
Maximum Adjusted Groundwater Table to the a`d Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished b-Y
56'
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� -\ COMMONWEALTH OF MASSACHUSETTS
W EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
> DEPARTMENT OF ENVIRONMENTAL PROTECTION
0
MAP —_
PARCEL • ® ��
LOT : 2
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 26 Willimantic Drive
Marstons Mills MA 02648 RECEIVED
Owner's Name: Mark Chiavelli
Owner's Address: Same FEB 2 5 2004
Date oi'Inspection: February 2,2004 TOWN
HEALTH DEp7-.A
B
L
E
Name of Inspector: PATRICK M. O'CONNELL EPT
Company Name: , SEPTIC INSPECTION SERVICES CO.
Mailing Address: 189 CAMMETT ROAD
MARSTONS MILLS MA 02648
Teleph-ane Number: 508-428-1779
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below i i 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: XO%JiOF
X Passes ��.� Q��•,....•M9SS+9�A
r
Conditionally Passes per' :yam
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: , Date: _2/2/04_
jspThe system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health��6�ltj
DEP) "ithin 30 days of completing this inspection. if the system is a shared system or has a design flow of 10,000
gpd of 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: Observed one foot standing water in overflow pit.
****Tliis 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
Page 2 A 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 26 Willimantic Drive,Marstons Mills
Ownor: Mark Chlavelli
Date of Inspection: February 2,2004
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_XX 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.
Comini,nts:
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.
Answei 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 imminent. System will pass inspection if the
existinE,tank is replaced with a complying septic tank as approved by the Board of Health.
*A mi:tal septic tank will pass inspection if it is structurally sound,not leaking and if at Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND exr lain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND ex f lain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass it,pection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND ex:lain:
I
Page 3 A 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Propi:rty Address: 26 Willimantic Drive,Marstons Mills
Owner: Mark Chiavelli
Date of Inspection: February 2,2004
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 fail in to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will,protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
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 thepublic health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
— The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
— The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory,for 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:
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Page-1 A I l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC;TION FORM
PART A
CERTIFICATION(continued)
Propo:rty Address: 26 Willimantic Drive,Marstons Mills
Owner: Mark Chiavelli
Date of Inspection: February 2,2004
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'/Z 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 forma
_No_ (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
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
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
'`yes"in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
A
Page 5 :)f 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 26 Willimantic Drive,Marstons Mills
Owner: Mark Chiavelli
Date of Inspection: February 2,2004
Chec.(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
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`'
{_ 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?
_X_ __ 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
condi:ion 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
maintariance 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
distarn.c-is unacceptable)[310 CMR 15.302(3)(b)]
Page 6 :)f I 1
43FFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Proparty Address: 26 Willimantic Drive,Marstons Mills
Owner: Mark Chiavelli
Date of Inspection: February 2,2004
FLOW CONDITIONS
RESIDENTIAL
Numhe of bedrooms(design): 2 Number of bedrooms(actual): 2
DESI G N flow based on 310 CMR 15.203(for example: 1,10 gpd x#of bedrooms): 220
Numbe-of current residents: 1
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundr✓system inspected(yes or no):
Seasonal use:(yes or no):No
Water meter readings,if available(last 2 years usage(gpd)): 2002
Sump pump(yes or no): No
Last da:e of occupancy: Currently Occupied
CO1V A IERCIALANDUSTRIAL
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):_
Indus.Tial waste holding tank present(yes or no):_
Non-:aititary waste discharged to the Title 5 system(yes or no):_
Water meter readings,if available:
Last c.a:e of occupancy/use:
OTH E R(describe):
GENERAL INFORMATION
Pumping Records: Last pumped three years ago.
Source of information: Owner
Was sy:,tem pumped as part of the inspection(yes or no)':'Yes
If yes, volume pumped:_1000_gallons--How was quantity pumped determined? Pumper truck sight glass.
Reason for pumping: Cesspool inspection
TYPE OF SYSTEM
Saptic tank,distribution box, soil absorption system
_S.ngle cesspool
_X Overflow cesspool
--Pri vy
_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
obtain eI from system owner)
_T:E,ht tank i Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Were,,owage odors detected when arriving at the site(yes or no): No
f
Page" if 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 26 Willimantic Drive,Marstons Mills
Owner: MarkChiavelli
Date of Inspection: February 2,2003
BUILDING SEWER: X (locate on site plan)
Depth below grade: 16"
Materials of construction:_X_cast iron _40 PVC_other(explain):
Distar ce from private water supply well or suction line: 22'
Comnie nts(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: No (locate on site plan)
Depth below grade: -
Mater:al of construction: concrete_metal_fiberglass__polyethylene
—other(explain)
If tank s metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certifi.:'Ite)
Dimensions:-
Slucigo depth: -
Distance from top of sludge to bottom of outlet tee or baffle: -
Scum dtickness: -
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'A ere dimensions determined: STICK WITH HINGE FLAP.
Comrr t nts(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as relatod to outlet invert,evidence of leakage,etc.):
GREASE TRAP: No (locate on site plan)
Depth below grade:_
Materi a 1 of construction:_concrete_metal fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distan,:e from top of scum to top of outlet tee or baffle:
Distan,:e from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comm;nts(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as reialud to outlet invert,evidence of leakage,etc.):
f
Page :3 A 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 26 Willimantic Drive,Marstons Mills
Ownt:r: Mark Chiavelli.
Date,A Inspection: February 2,2004
TIGF[T or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other(explain):
Dimem ions:
Capac ily: gallons
Desig.i Flow: gallons/day
Alarrr present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Conmients(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: No (if present must be opened) (locate on site plan)
Depth cif liquid level above outlet invert: -
Comrrtents(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
PUMP CHAMBER: No (locate on site plan)
Pump: in working order(yes or no):
Alarm 3 in working order(yes or no):
Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.):
Page 9 A 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 26 Willimantic Drive,Marstons Mills
Owner: Mark Chiavelli
Date ol'Inspection: February 2,2004
SOIL,/kBSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
_X_overflow cesspool,number: One 6x6 Precast pit.
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.): Observed one foot standing water.
CESSPOOLS: X (cesspool must be pumped as part of inspection) '(locate on site plan)
Numbe and configuration: One with overflow
Depth- top of liquid to inlet invert: 8"
Depth cif solids layer: 10"
Depth of scum layer: 3"
Dimens ions of cesspool: 6'dia.x 6' deep
Materials of construction: Block
Indication of groundwater inflow(yes or no): No
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
Liquid level at bottom of outlet pipe.Cesspool is structurally in good condition.
PRIV V: No (locate on site plan)
Materials of construction:
Dimens ions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.):
Page 10 of l I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Propj.rty Address: 26 Willimantic Drive,Marstons Mills
Owner: Mark Chiavelli
Date of Inspection: February 2,2004
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including,ties to at least two permanent reference landmarks or
benchrr arks.Locate all wells within 100 feet.Locate where public water supply enters the building.
Willimantic Drive
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Page 11 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 26 Willimantic Drive,Marstons Mills
Owner; Mark Chiavelli
Date i0'Inspection: February 2,2004
SITE EXAM
Slope None
;Surface water None
Check cellar Dry
Shallow wells None
Estimated depth to ground water: More than 20 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)
C iecked with local Board of Health-explain: _
C iecked with local excavators,installers-(attach documentation)
_X_Accessed USGS database-explain: USGS topo map and town GIS
You m ust describe how you established the high ground water elevation:
Topo map shows property above el.70.Town groundwater contour map shows water below el.45.
MAP j v 3 LOT
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DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: (O O•,LL i en prk)-T %C b
Mft9Mb z M�t-Ls
Owner's Name: -So—SG Pl+ ("L-ot�
Owner's Address: 5/1M
Date of Inspection: 3 .a.1 p 1
Name of Inspector: Dion C. Dugan
Company Name: 1543 Main St.
Mailing Address: Brewster, MA 02631
Telephone Number: (508)896-9390
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant t Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
/
Inspector's Signature: �--�C� �✓ Date: 3/2 O /
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DF,P)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 ('omments * Recommend: Maintenance pumping every 3 - 5 yrs.
'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.
I ilr jw;pciliun I olm 6/15/2000
Pagc 2 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: W 1 L�-, .yAANT i c h9-.
--
Owner: --ShSL3'P►V MA Lr�N Ly-1
Date of Inspection: 3 1 a-1 0 I
inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. ystcm 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:
System Conditionally Passes:
e or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not termined(Y,N,ND)in the for the following statements. If"not determined"please
explain.
The septic tank is metal an over 20 years old* or the septic tank(whether metal or not)is structurally
unsound,a hibits substantial infiltrat or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complyin eptic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if i i structurally sound, not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old available.
ND explain:
Observation of sewage backup or break out or high sta ' water level in the distribution box due to broken or
obstructed F.ipe(s)or due to a broken,settled or uneven distributio box. System will pass inspection if(with
approval of Board of Health): I <
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 pip s). The system will
pass inspection if(with approval of the Board off-lealth):
broken pipe(s)are replaced
obstruction is removed
ND explain:
I'age 3 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: ate WiLf _i MAN T C_ S�(Z
0r)41?-5 1ION s /Vt I C s
Owner: TQSEPH MALONG`t
Date of Inspection: .3)a 101
C Further Evaluation is Required by the Board of Health:
onditions exist which require tiuther evaluation by the Board of Ilealth in order to determine if the system
is failing protect public health,safety or the enviromuent.
1. System ill pass unless Board of Health determines in accordance with 310 CNIR 15.303(1)(b) that the
system is t functioning in a manner which will protect public health,safety and the environment:
Cesspool o rivy is within 50 feet of a surface water
_ Cesspool or p is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board o ealth(and Public Water Supplier,if any)determines that the
system is functioning in a manner that pr ects the public health,safety and environment:
_ The system has a septic tank and soil ab tion system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface wa r supply.
The system has a septic tank and SAS and the S is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is 'thin 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less th 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 certi d laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from p lution from that facility and
the ipresence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 m,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
t t III
......... :....
Page 4 ol,I I
OFFICIAL INSPECTION FORM — NOT FOIL VOLUNTARY ASSESSMENTS
SU13SURFACE SEWAGE DISPOSAL SYS ,EM INSPECTION FORM
PART A
CERTIFICATION (continued)
Properly Address: a(o W;L_i,; 4AjQ-PC, Dt?-.
1 STOO S M
Owner: J-bSL-Pr� MPrOoNe",4
Date of Inspection: 3 1 y
D. System Failure Criteria applicable to all systems:
You must indicate`yes"or"no"to each of the following for all inspections:
Yes Nz)
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
/Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
I of times pumped
_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public well.
/ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory, for 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.]
(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design,flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
N/A
the system is within 400 feet of a surface drinking water supply
N/A J
_ _ fhe system is within 200 feet of a tributary to a surface drinking w:af&supply
N/A—
he
system is located in a nitrogen sensitive :area(Interim Wellhead Protection Area - IWPA)or a mapped
Zane II of a public water supply well
Il'you have:answercd "yes"to:any question in Section F the system is considered a significant thrc;H, of answered
yes" in Section 1)above the large system has Iailcd 'I lie owner or operator of;any I;arge system con.si(lcrcd a
significant threat under Section 1:of failed under Section 1)shall upgrule the sysicm in accoidamc with 310 CMlt
I S-104. The system owner should contact the appropriate regional olficc of the Ucp;uloacrai.
llagc 5 of' I I
Oi r,ICIAL INSPECTION FORM - NOT FOIL VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART 13
CHECKLIST'
Property Address: _ a(o W,\��mA►1T�I�K ,
_ t 1�HiZSTo tJ S M u.s
Owner: J OSEp or MA-t_c^j Z4-
Date of Inspection: _ 3 1-11.p t
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Ye No
Pumping information Aas provided by the owner,occupant, or Board of Health
Were any of the system components pumped out in the previous two weeks?
1� _ as the system received normal flows in the previous two week period?
_ Have large volumes of water been introduced to the system recently or as part of this inspection?
V _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
_ Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
Were all system components,excluding the SAS,located on site?
_ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
o the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
A/ _ Was the facility owner(and occupants if different from owner)provided with information on the proper
nc maintenae of subsurface sewage disposal systems'?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on
Y 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)]
t
Page G of I I
,
OFFICIAL INSPECTION FORM -- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: -2(p
Mftes'C JQ S )A i L-k-<,
Owner: Z306k✓:' k-�- NSA- f\)GI-71
Date of Inspection: 3 2 j pl
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):_2k—
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x N of bedrooms): 336
Numrber o:f current residents: 4
Does residence have a garbage grinder(yes or no): AJO
Is laundry on a separate sewage system(yes or no):& [if yes separate inspection required]
Laundry system inspected(yes or no):�Q
Seasonal use:(yes or no):V
Water meter readings,if available(last 2 years usage(gpd)): 9WO `f9,000 gals. 1999 1 ,000 gals.
Sump purrp(yes or no):
Last date of occupancy:
C OMMERCIA IANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15. 03 : 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: 82161A21AJ A✓N6*L
Was systerr_pumped as part oft the inspection(yes or no):_
If yes,volume pumped: gallons--flow was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
Eli
c lank,distribution box,soil absorption system
e cesspool
flow cesspool
Privy
AQ 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 frorri system owner)
Fight tank __Attach a copy of theDI-T approval
Other((.escribe):
Approximate age of all components, date installed (it known)and source of infornwlion:
A�nn�Ro �r�,�fty_ _/AGO N�l� L�Ac N ��iT.fJL Eb /ySrO �Q 0.H
Wcrc sewage odors dctcctecl when arriving at the siic (ycs or no): Na
...........:.... i:...... i.ii nnni (,
I'age7ofII
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 2lio VJ;LA-;
fYIPrQ-sTOI�JS M��t-�_
Owner: �r} iV\k'0M cry
Date of Inspection: 3)--1 O t
BUILDING SEWER(locate on site plan)
Depth below grade: Z� 3
Materials of construction:_cast iron 40 PVC_other(explain):
Distance fi-om private water supply well or suction line:
Comments(on condition of joints,venting, evidence of leakage, etc.):
,7o- ,A is #,ek rjcNr, UJEAU746 Ar AJQ sisNs 61'::' Z'e:44
SEPTIC TANK: (locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_fiberglass_polyethylene
other(explain)
If tank is.petal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
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:
How were dimensions determined: by tape and rod
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
* Recommend: Maintenance pumping every 3 - 5 yrs.
GREASE TRAPI locate on site plan)
Depth below grad
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 lee or haffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
I
I'abe 8;if I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENT'S
SUI3SUIZFACE: SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: �t:'_lo►}- A y%-o.Q t3�4
Date of Inspection: 3 JZ.jol
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 odier(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 present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
PUMP CHAMBER:N1
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 I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PA R'1' C
SYSTEM INFORMATION (continued)
Property Address:_ o(o Wiwi Al�wl c,c. na
Owner; �SeP1� mi9w�VLy
Date of Inspection: 2 0
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Tye
leaching pits,number:nvc- as XG k e qCN P17,
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.):
e 7" �Oe�iy,0 i„/1-2.-j", e,2 /Ai i ir`,,_Ak2 S Qa= Z,q, R
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: CAJA (CON V-47A&b 7'-,A,0 SF�P IG,E (p
Depth—top of liquid to inlet.invert: g'�
Depth of solids layer: B"`
Depth of scum layer:
Dimensions of cesspool:
Materials of construction: 6LocK
Indication of groundwater inflow(yes or no):Np0jj4
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
rRM/'1,6 �D PIE 66 P ,l, *,6 LLA4&) , A,b -51G IS OF FA,6affe_ ,
' Recommend: Maintenance pumping every 3 5 yrs
pRryY: N/A (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 vege(ation, etc.):
r
Paf;e 10 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: .2 1p W�LL i MAw�,<-
t'Y1HrSTQ0S
Owner: ,Tr���pr1 M�4tAt 1
Date of Inspection: ;3)al
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permvient reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
oD
- C - 31 '
A - ,b _ s� ,G ".
A �
(� - C - 26
H Ovs E -*z G
v� J
r � t
I
w
blz�
Page I I of' I I
OFFICIAL, INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: a 10 W t���.MAN� ,(, & .
_fbflQ-ST o lJS M 1 L.4-t
Owner:_ T06jyP& MPtt_pNt�
Date of Inspection:
SITE EXAM
Slope
Surface eater
Check cellar
Shallow wells
Estimated depth to ground water�tZ 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:
15y AfLz;1s H 4 - G 9
t P
°== COM-NION-WEALTH OF NIASSACHUSETTS
EXECUTIYE OFFICE OF EN IROKME.N TAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
I N � 1i� 292-��OlONERN : 2 t h
UDY CORE
Secretan,
ARGEO PAUL CELLUCCI 141 l� e DAVI-D B. STRUHS
Governor �Yotnmiss:cner
SUBSURFACE SEWAGE DISPOSAL ART A SYSTEM INSPECTION RM I999
CERTIFICATION
�'.TT'i�•+�:.� � ��;va�,•e.� Mgr
Property Address: wtw-v,L Name of Owner
Lxxv
O I ol.S M(1 Address of Owner: G 7i
Date of Inspection:Z�:�\Cin
Name of Inspector: (Please PHnt) C�
I am a DEP approved system inspector pursuant to Section 15.340 of True 5(310 CMR 15.000)
Company Name: &:k &-1 '✓rY b. k%s C N
Mailing Address:�?,-72 /Z,y a 2 -7.'?4•
Telephone Number: / .51C041 L -;z
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 prcper function and
maintenance of on-site sewage disposal systems. The system:
Passes
_ Conditionally Passes
_ Needs Furthe v i ike,Local Approving Authority
_ F 'Is
Ins pector's.Signature: L` Date:
The System Inspector shall 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 of Environmental Protection. The original should be sent to the
system.owner and copies sent to the buyer, if applicable, and the approving authority.
NOTES AND COMMENTS
a
revised 9/2/98 Page Iof11
;= Pr.rded on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
r
"roperry Address: a+� Ititl� y1Y�TlC�
Jwner:
Date of Inspection: 13\cF�
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
I 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.
Indiczte yes, no, or not determined(Y, N, or NO). 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 prior to the date of the inspection; or
the septic tank, whether or not metal, is 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 complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven 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 levelled 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
revised 9/2/98 Page 2of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (contirwed)
Property Address:
Owner:
Date of Inspection:
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 s stem is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 R 15.303(1)(b)THAT THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAF AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt rsh.
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,/AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water anilysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and/fhe presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER /
i
1
i
c
revised 9/2/98 Page 3of11
y
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 31 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine w t will be necessary to correct the failure.
Yes No
Backup of sewage into facility or system component due to an overloaded clogged SAS or cesspool.
_ — Discharge or ponding of effluent to the surface of the ground or surfac waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or avail le volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year N due to clogged or obstructed pipe(s).
Number of times pumped_.
_ Any portion of the Soil Absorption System, cessp of or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 1 feet of a surface water supply or tributary to a surface water supply.
_ Any portion of a cesspool or privy is withi a Zone I of a public well.
_ Any portion of a cesspool or privy is w' hin 50 feet of a private water supply well.
Any portion of a cesspool or privy i 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
ammonia nitrogen and nitrate nitrogen.
ria volatile or 9
coliform bacteria, organ' compounds, am 9
E. LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" to ch of the following:
The following criteria apply to lar a systems in addition to the criteria above:
d greater(Large The system serves a facility th a design flow of 10,000 „ or� System) and the system is a significant threat to public
health and safety and the a ironment because one or more of the following conditions exist:
Yes No
the system rs 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 operaior 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.
s
revised 9/2/98 Page 4of11
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property, � �Address: �Q wI (
Owner: Lok Q v')\C4->
Date of Inspection: \����
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes fVQ
Pumping information was provided by the owner, occupant, or Board of Health.
_ None of the system components have been pumped for at least two weeks 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.
_ 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.
The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
—C — All system components, excluding the Soil Absorption System, have been located on the site.
_ The septic tanl 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 on the site has been determined based on:
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);
- _ The facility owner (and occupants,if different from owner) were provided with information on the propermaintanaac6-0f
SubSurface Disposal Systems.
rev=sed 9/2/98 Page 5ofII
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
'roperty Address:,Ike Wi t OAnKJJQ,
Owner: ( �A ea V 1t.12`
Date of Inspection:of�31 cf�
FLOW CONDITIONS
RESIDENTIAL:
Design flow:• �0 g•p.d./bedroom.
Number of bedrooms (design): Number of bedrooms (actual): 03
Total DESIGN flowC�
Number of current residents:
Garbage grinder(yes or no):-Ig
Laundry(separate system) ( es or�:_: If yes, separate inspection required
Laundry system inspected yes r no)
Seasonal use (yes or no):� \
Water meter readings, if available (last two year's usage (gpd): IV
Sump Pump(yes or no): `j)
Last date of occupancy: SI �
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: qpd ( Based on 15.203)
Basis of design flow
Grease trap present: (yes or no)_
Industr*ai 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:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of infor tion:
System pumped as part of inspection: (yes or�
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
Septic tankldistribution box/soil absorption system
—Al Single cesspool �OUctFL �tQ II
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed Iif known) and source of information: IL�
_ N't-W is I
h Sewage odors detected when arriving at the site: (yes or no)
s
revised 9/2/98 Page 6ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
'roperty Address:
Owner:
Date of Inspection:
BUILDING SEWER:
(Locate on site plan)
Depth below grade:_
Material of construction:_cast iron—40 PVC_ other (explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting, evidence of leakage,-etc.)
SEPTIC TANK:—
(locate on site plan)
Depth below grade:_
Material of construction:_concrete—metal—Fiberglass _Polyethylene other(explain)
If tank is metal, list age_ Wage confirmed by C/e:_
nt _ (Yes/No) -
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee
Scum thickness:
Distance from top of scum to top of outlet tee or ba
Distance from bottom of scum to bottom of outlet tHow dimensions were determined:
'omments:
(recommendation for pumping, condition of inlet andes, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
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 sc/ing,
f outlet tee or baffle:
Distance from bottom oottom of outlet tee or baffle:
Date of last pumping:
Comments:
(recommendation for pudition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert; structural integrity,
evidence of leakage, etA
i
f
t
C
f
l
I
`r.
revised 9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
'roperty Address:
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 grade:_
_metal _Fiberglass_Polyethylene_other(explain)
Material of construction: _concrete
Dimensions:
Capacity:_gallons
Design flow: gallons/day
Alarm present
Alarm ievel: Alarm in working order: Yes — No_
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet invert:
J
Comments:
ge into or out of box, etc.
(note if level and distribution is equal, evidence of solids carryover, evidence of leaka
i
PUMP CHAMBER:_
(locata 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.)
n
Page 8 of 11
revised 9/2/98
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
qq SYSTEM INFORMATION (continued)
lroperty Address:/'(g 0-iItwQ.,�1�,
Owner:Lklp((/Kvl--
Date of Inspection:t3jj
SOIL ABSORPTION SYSTEM(SAS):-LV—S
(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:-A&'X
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 hydraulic failure, vel of ponding, damp soil, con(fitiQ,n of eta ' n, etc.)
r
Aj
t
CESSPOOLS: .
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert: (0
Depth of solids layer: L`t
)epth of scum layer: „ *
Dimensions of cesspool: 5b(KA (0
Materials of construction: Cc �cslar ` �
Indication of groundwater: gt
inflow (cesspool must be pumped as part of inspection) v c_�'— py,t.�� r Tl�lh' ��
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of veget tkon,
0"1—
PRIVY: INC)
(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.)
s
revised 9/2/98 Page 9of11
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (contirwed)
I
'roperty Address: OZ(o W ( ' aAar-rT(i
Jwn
DateofIn"Te Inspection:
Date of Inspection: 13 I ^
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)
t
al
1
Pi t 3y
revised 9/2/98 Page Ili of II
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
tt����"" SYSTEM INFORMATION (continued)
roperty Address: /-u CA-,
Owner: LAP-tvlzd.L
Date of Inspection:
Ot�3
1
NRCS Report name --
Soil Type_ — -
Typical depth to groundwater _ _
USGS Date website visited NV
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope NCB
Surface waterpip.
Check Cellar Tj"
Shallow wells p 1#4,
Estimated Depth to Groundwateri2o(Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site (Abutting property, observation hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators, installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
` c" C) CC
U t SSZap"
revised 9/2/98 Page 11of11
TOWN OF BARNSTABLE
LOCATION_6 9(LLl u-*"-ttc. R SEWAGE # o
VILLAGE CAA��,S 0--) `iAILL5 ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY �Xn Ski G- CAS hod�--
LEACHING FACILITY:(type) �l `T' (size). '`aov 6r4-
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER_��gliC
BUILDER Opt, OWNER (`ut C �� N
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED_
VARIANCE GRANTED: Yes No.
- -,
��
,fih S�
,..,-t,1-�cnV
I.
�^��
_ � � ��
_t..
No._ l6•-3 ! Fss..............
3��
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratintt for Disposal Works Tons inn rrutit
Application is hereby made for a Permit to Construct ( ) or Repair (Tan Individual Sewage Disposal
System at:
.......... ............................... ..•---------•-------.. ,�
e Locat dre �q/v
....
net Address '
� Installer Address -�
d Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms.......... .........................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons____________________________ Showers — Cafeteria
P4 Other fixtures ------------------------------•• -
w Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length-----------_--- Width................ Diameter---------------- Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
�-' Percolation Test Results Performed by---------------------------
--•------------------•------•----------.------ Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
LT4 Test Pit No. 2----------------minutes per inch Depth of Test Pit....:............... Depth to ground water--------_...............
9 •-••-•---••••---•-•-••••••••------••••••-••••--•--••-••--•---._....-•-------•-...•---•--•---••--•---.........................................................
0 Description of Soil---------------------------------------------------------------------------------------------------------------------...-----------•---•--....--------•--•------•--•--.
x
U ......_..••••••--•••••••-•--••-•-•••••••--•-•----•-•--•-•-•...................••---•••----•-----•--•••-------•-•--••-•--•••••--•-•••-•••--••----•----••-•-•----••-•-----•-----------•----•-•--•---...••--
w
VNature of Repairs or Al eratio s—Answer w applicable___
�? .. .....�.��-..61�a -- ..-----dam ► .. .p°------ -= w�
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance s been issued by t oard of health.
j
Signed ---- -- ` —
Date
Application Approved BY .— �'�`��� — � .. -----
Date
Application Disapproved for the following reasons- ---------------------------------------------------------- ----------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------
Date
Permit No. --------c---- ---_----�--3-��-- Issued r --^--.. ( o
to
-------------
f
No.._ ._.�_ .... Fs$.................
_....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratiou for 14spnual Iforkii TvtwtrurPvtt Famit
Application is hereby made for a Permit to Construct ( ) or Repair ( V) an Individual Sewage Disposal
System at
or Lot Nm
._...... ............ =......_-_2� ad--MA/!✓�............. .......�t/l//i�YJ<4.e/J`i ✓�/L._..........---_-
3S n Address
w C„ - 172k, se / �-/.
........... -------- =...
Installer Address p
Type of Building Size Lot____________________________Sq. feet
V Dwelling—No. of Bedrooms.___.._.___________________________Expansion Attic ( ) Garbage Grinder ( )
Pk
Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures -----•-----------------------------•------------------•••---•-------------••-•••-•-•--•---••------------•••----------•---....------------••-•--------
w Design Flow............................................gallons per person per day. Total daily flow.............................................gallons.
WSeptic Tank—Liquid capacity------------gallons Length................ Width................ Diameter....._.......... Depth................
x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Degfh below inlet.................... Total leaching area..................sq. ft.
Z Other'Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by------- - ..............=-- Date.......................................
Test Pit No. 1________________minutes per inch Depth of Test Pit____________________ Depth to ground water_______--___________---.
fT4 Test Pit No. 2................minutes per inch Depth of,-Tes Pit__-_________________ Depth to ground water........................
-------------------------------------
•-------------------------------------------------------------------------------•---------------------------
...
ODescription of Soil........... ---------------------------------------------------•-•---•---------------------------------------•-••-------------------------------------••-•---------•-
x
U --------•------•-•-••------•••------------•••---•••--------------------------------••--•---•---•--•-••--------•-------------••--••--•-------•-••----••--••-••-----••-.._.......•--...-------•-----..___.
UW ------------•---
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 TITLE 5 of the State Environmental 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
(/ Date
Application Approved By -- -- --- -----------------"'-'-- --�--�C�
.............. ..............'----'.............................................................-'----- Dare
Application Disapproved for the following reasons- --------------"-'--'--'---'---'-----'------------'-----'---....---'-----...............................................................
-------------------- -----------'---'---"-- --------. ---------'--...--------'---.............--- -------------------- ------------------------..........................------------- ----------------------------------------
. ^ C 3 ^lj <_ Dale
Permlt No. ------- .........."""'---"-...... Issued ..................?3........ ............. - ----------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
%Eez#mutt#e of C'ILlmytian e
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by c��i r am_ C,v t .�- - " ...-...
at ----.C.+////_Js'Jf��,l�t�' ( tG[, /P Jiv -..A74/f
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. --�� ....'.?� .............. dated ...... 7�--1.....S.v.-------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRU�6'_A' S A GUAItAN'TE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE .- --.�1......................................-------------------'-------------'---- Ins ector --- --
iP v....-......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
3cfy TOWN OF BARNSTABLE ,o0
No ................ FEE........................
11isposal Workii Toni#rntuan rrmi#
Permission is hereby granted...... �._........S....................f...
to Construct ( ) or Repair ( ✓�an Individual Sewage Disposal System
at No.... ,...... .........¢ /l/�. , �-
Street
as shown on the application for Disposal Works Construction Permit No._�Q___� Dated...... k ............
E3BoardtHealth
DATE................................................................................
FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS
No.------- - - ----- _ Fee----2-----------------
BOARD OF HEALTH
TOWN OF BARNSTABLE
Application-*rVell Con5tructionpermit
ApDlication is hereby made for a pe it to Construct (, ) Alter ( ), or Re air ( a .dividual Well at:
Location - Address - Assessors Map and Parcel
��------------------------------------- --------------------------
Own Address
-----'--- - - ---- - -
Instal er =Duller Address
Type of Building
Dwelling--------------------------------------------------------------
Other - Type of Building No. of Persons---------�)_ x-�---------------------
Ty I pe of Well- N
! -� - ---- Capacity-
--3� �w-N-------------------------
�Purpose of Well-- p`!A1 E=----- -
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to
place the well in operation until Certificate of Complian has been issued by the Board of Health.
Signed— - ---- - — — -.— - ----------------------------
date
Application Approved By---- --- ----- ��'� -1 L
---1------------- ----------------
date
Application Disapproved for the following reasons:-------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------—------------------------
" date
22
Permit No. -—�V '--�-3 - - - - --- Issued------------------ - =¢-----�`---------------------------------
date
7----- --- --- — - ----- --I
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate Of Compliance
THIS IS TO CERTIFY, Th((att the Individual Well Constructed ( ), Altered ( ), or Repaired ( )
bY- - — -ems;t - - ---- -- -- -_—_-------------------------------------------- - - -
Installer
( <<_ "�-Ott e _M,t_
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well P otect'on
Regulation as described in the application for Well Construction Permit No. -- - - ----Dated-------------a-----
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE - ----------------------------------------- ----------------------- Inspector-------------------------------------------------------------
No. -`=---i-- Fee- ---
BOARD OF HEALTH
TOWN OF BARNSTABLE
Application-*rVell Con5truttion3permit
Application is hereby made for a pe. it to Construct ( )r Alter ( ), or Repair ( an individual Well at:
_—v A_ t'_�_�_ '�4 '.r ------------- -- -�� - —`"�-- --—- - -
Location — Address Assessors Map and Parcel
- --------------------------------
J/ �O,�wn�er ------------------- Address
Installer'— Driller Address
Type of Building
Dwelling-- - ---------------------------------------------------
Other - Type of Building No. of Persons-
Type of Well ---- - Capacity_- -- --- - ---------------
Purpose of Well---
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to
place the well in operation until �Certificateof Complianeq has been issued by the Board of Health.
Signed---- ----- -------------------
ad�e
Application Approved By -c�---------------------------------------------- li
-- ----date
Application Disapproved for the following reasons:
—date
1f�C-t �--` ! 3 -- —— Issued — —J-2 Z 9 2_ —— date --
Permit No.- --- -- — - — - —
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate Of Corr phance
THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repairedby ( )
—----------------- - - ------------
_ -- L Installer
at----------
---_ - -- - — --
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well P/rotectiion
Regulation as described in the application for Well Construction Permit No. t)�i�-2---1-'---Dated---)-/j-- �-V-5
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE------------------------------------------------------------------------------------- Inspector---------------------------------------------------------------------------
BOARD OF HEALTH
TOWN OF BARNSTABLE
Ivell con5tructioni3ermit
No.---------------------- Fee ---
Permission is hereby granted---------.
to Construct ( ), Alter ( ), or Repair ( �) an Individual Well at:.
0/ W W,l t. I MiM� -.- IV Q_ U M 1 t
Street
as shown.on the application fora Well Construction Permitrr �
No. w G t ----- Dated------`-�?1 /� Z
- -- -- ---- ----- ----- -- --
--------------------- -----------------------
_ Board of Health
DATE - - --- ---------------------------------------