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HomeMy WebLinkAbout0068 WINDING COVE ROAD - Health 4 68 Winding Cove Road Marsions Mills:4'5, "' f VN A `057 016 6r ® 3 UPC 12934 No. 2�153L�Y �bn.cor�°do- NARTIN(Iq MN r !' i � i .�-''� I I r I I � i i t \� v COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION h M Q V� 5�a Ricky L.Wright- Certified Title V Inspector,508477-0653 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 68 Winding Cove Road "'I ^'� Marston Mills,MA -� Owner's: David Whiteside Q Z Owner's Address: 68 Winding Cove Road j "' O T Marstons Mills,MA 026481 ( flo Date of Inspection:October 15,2009 "' Name of Inspector:Ricky Wright -License#514595 ti Company Name:B&B Excavation,Inc. rya Mailing Address: 14 Teaberry Lane rrn Forestdale.MA 02644 Telephone Number: 508-477-0653 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 to Section 15.340 of Title 5(310 CMR 15.000). The system: _X Passes _Conditionally Passes _ Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Tom` /y- 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: The information as identified represents only the condition of the system on--------at_ PM. ****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. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 68 Winding Cove Road Marstons Mills,MA Owner's: David Whiteside Owner's Address: 68 Winding Cove Road Marstons Mills,MA 02648 Date of Inspection:October 15,2009 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer es no or not determined N ND in the for the following statements.If"not determined"please yes, �, ) g explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced (THIS IS REQUIRED TO BE COMPLETED) 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: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 68 Winding Cove Road Marstons Mills,MA Owner's: David Whiteside Owner's Address: 68 Winding Cove Road Marstons Mills,MA 02648 Date of Inspection: October 15,2009 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(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 the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for 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: f Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 68 Winding Cove Road Marstons Mills,MA Owner's: David Whiteside Owner's Address: 68 Winding Cove Road Marston Mills,MA 02648 Date of Inspection:October 15,2009 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'h day flow X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. X— Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X_ Any portion of a cesspool or privy is within a Zone 1 of a public well. X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] _NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 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. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 68 Winding Cove Road Marstons Mills,MA Owner's: David Whiteside Owner's Address: 68 Winding Cove Road Marstons Mills,MA 02648 Date of Inspection:October 15,2009 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No X_ _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X Has the system received normal flows in the previous two week period? X_ Have large volumes of water been introduced to the system recently or as part of this inspection? _X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ _ Was the facility or dwelling inspected for signs of sewage back up? X_ _ Was the site inspected for signs of break out? _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 condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _X_ _ Existing information.For example,a plan at the Board of Health. _ _ 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: 68 Winding Cove Road Marstons Mills,MA Owner's: David Whiteside Owner's Address: 68 Winding Cove Road Marstons Mills,MA 02648 Date of Inspection: October 15,2009 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_Number of bedrooms(actual):3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x 3 of bedrooms):330 Number of current residents:4 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]NO Laundry system inspected(yes or no):YES Seasonal use:(yes or no):NO Water meter readings,if available.N/A Sump pump(yes or no):NO Last date of occupancy:CURRENT COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:_OWNER Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: . TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system(6'pit with 2' stone) _Single cesspool _Overflow cesspool _Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Altemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information:Approx. 10/2/85 Were sewage odors detected when arriving at the site(yes or no):NO f Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 68 Winding Cove Road Marstons Mills,MA Owner's: David Whiteside Owner's Address: 68 Winding Cove Road Marstons Mills,MA 02648 Date of Inspection:October 15,2009 BUILDING SEWER(locate on site plan) Depth below grade:31" Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line:_NA Comments(on condition of joints,venting,evidence of leakage,etc.):at time of inspection,pipes and joints appear to be in good condition SEPTIC TANK: (locate on site plan) Depth below grade:24" Material of construction:_X_concrete_metal_fiberglass_polyethylene_other(explain)_ If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 10'6"x 518"X 5'5" Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness:NONE Distance from top of scum to top of outlet tee or baffle:N/A Distance from bottom of scum to bottom of outlet tee or baffle:N/A How were dimensions determined: _actually measured Condition of tank(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.) at time of inspection,tank appeared to be in good condition. T's&baffles were present GREASE TRAP: Depth below grade Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 68 Winding Cove Road Marstons Mills,MA Owner's: David Whiteside Owner's Address: 68 Winding Cove Road Marstons Mills,MA 02648 Date of Inspection: October 15,2009 TIGHT or HOLDING TANK: N.A._(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/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:_X must be opened) — if resent( P P ) Depth of liquid level even with outlet invert:liquid level is above the 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.):at time of inspection,D-Box was in good shape with no signs of carryover or leakage PUMP CHAMBER:,(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 68 Winding Cove Road Marstons Mills,MA Owner's: David Whiteside Owner's Address: 68 Winding Cove Road Marstons Mills,MA 02648 Date of Inspection: October 15,2009 SOIL ABSORPTION SYSTEM(SAS):_(locate on site plan,excavation not required) If SAS not located explain why: Type X_leaching pits,number 1 _leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions_ _overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etch CESSPOOLS:_(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater'inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:_(locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 68 Winding Cove Road Marstons Mills,MA Owner's: David Whiteside Owner's Address: 68 Winding Cove Road Marstons Mills,MA 02648 Date of Inspection: October 15,2009 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. C A'' B Ai - 3S' ,31 - 13 ' A3 - ys' Z C 3 -,39, O i Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 68 Winding Cove Road Marstons Mills,MA Owner's: David Whiteside Owner's Address: 68 Winding Cove Road Marstons Mills,MA 02648 Date of Inspection: October 15,2009 SITE EXAM Slope 1% Surface water NONE Check cellar YES Shallow wells NONE 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: _X_Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain:Recent Test Holes, Existing engineer records with BOH Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Based on information in the Board of Health the ground water in the area appears to be approx. 10'below grade. y COMMONWEALTH OF KksSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION mAP PARCEL OT TITLE 5 �- OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS --� SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: t/ -A Owner's Name: Owner's Address: - - ��� RECEIVED Date of Inspection: Name of Inspector: please rint F APR 3 U 2004 Company Name: - C., Mailing Address: (7 ' �!D TOWN OF BARNSTABLE �cDY~0 HEALTH DEP.T. Telephone Number: ,Q�9- 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 Dl P approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority rail V 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 6/15/2000 page 1 Page 2 of 11. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1 Owner: Date of Inspection:. Inspection.Summary: Check A,B,C,D or E./ALWAYS complete all of Section D A. /System Passes: tl I have not found any information which indicates that any-of the failure criteria described ill)IO*CMR' 15:303.or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B: System Conditionally Passes:. l 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. 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 imminent. System will pass inspection if the existing tank.is replaced with a.complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed.pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced 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 r Page 3 of 1'1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address AM Owner. Date of Inspection: Mo C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system' is failing-to protect public health, safety-or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(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 the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100.feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A•copy of the analysis must be attached to this form. 3. Other: Page 4 of I l OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION.(continued) Property Address: 691.g Atf& Owner:OwnerAgkA I Date of Inspection: ` D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes N 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 '/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. 1/ 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) 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. '4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM CHECKLIST Property Address: Ch " Owner: Date of Inspection: Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes o Pumping.information was provided by the owner,occupant, or Board of Health ZWere.any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? v 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? y 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? Was the facility owner(and occupants if different from owner).provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes o Existing information. For example, a plan.at the Board of Health. _U_ 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)] 5 Page 6 of l l OFFICIAL INSPECTION-FORM—NOT FOR VOLUNTAR . Y ASSESSMENTS SUBSURFACE SEWAGE`DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner:. Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):- Number of bedrooms(actual): DESIGN flow based on 310,CMR 15.203 for example.- 11.0 Q d x 4 of bedroom s): ms Number of current residents: /-a Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system (yes or no [if yes separate inspection required] Laundry system inspected(yes or no Seasonal use:(yes or no.:e Water meter readings, if available(last 2 years usage(gpd))- 0 WA61)^ 0✓—1751-AW Sump pump(yes or no). *- Ie Last date of occupancy:��¢ y f...� COMMERCIALANDUSTRIAL/-�& 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: P� j IMn Was system pumped as part of the inspection(yes or no): If yes, volume pumped: gallons;-How was quari ty pumpe&determined? Reason for.pump ing- TYP 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): proximate age of all co po ents, dat inst f (if known)and source of information: Were sewage odors detected when arriving at the site es or no): 6 Paee 7 of 1 3 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address• CX�' i4 Owner: wm; Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting, evidence of leakage, etc.): SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction: concrete_metal_fiberglass_polyethylene _othef(explain) If tank is metal 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: Z�. Scum thickness: C Distance from top of scum to top of outlet tee or baffle: 2— Distance from bottom of scum to bottom of outlet tee or baffle:_ How were dimensions determined: o--htin(� /) Comments(on pumping recommendation , inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc. . f i GREASE TRA I&-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.: C/ ' Owner: Date of Inspection: TIGHT or HOLDING TANK: /tank must be pumped at time of inspection)(locate.on site plan) Depth below grade: / T� 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:—V—/(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) { (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 o pumps and appurtenances, etc.): 8 Page 9 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Q Owner: Date of Inspection:SOIL ABSORPTION ABSORPTION SYSTEM (SAS): V(locate on site plan,excavation not required) If SAS not located.explain why.: Type eaching 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, elzt. ` L A i7�_IM 6&4 CESSPOOL(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: j)(l.ocate 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 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART C SYSTEM IN.F.ORMATION(continued) Property Address: Owner• Date of Inspection: v 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. Z`a ti !}L o 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: Iq- Owner: Date of Inspection: 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: e"r/ f �O�r XV b 11 f Permit Number*, Date: Completed by: - 51 HIGH GROUND-WATER LEVEL COMPUTATION Site Location: �1� W / Cates i" �`�� ✓C/(� Lot No. Owner: j�11,�,, Address: Contractor: �0✓ Address• Notes: STEP 1 Measure depth to water table l to nearest 11/10 ft. .............................................................................. .Date month/day/Year STEP 2 Using Water-Level Range Zone and I-idex Well Map locate site and determine: OAppropriate index well............................................... OW'ater-level range zone ........................................I............ C STEP 3 Using monthly report "Current Water Resources Conditions" J determine current depth to water level for index well ..........................• month`/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 28) i, determine water-level adjustment ........................................................................................... STEP 5 Estimate depth to high water by subtracting the water- levO adjustment (STEP 4) r from measured depth to water rlevel at site (STEP 1) ............................................................................................................. Figure 13.--Reproducible computation form. 15 .p 1 I ICI COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS ,. j r DEPARTMENT OF:ENVIRONMENTAL PROTECTION ;o TITLE 5 . OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASS 1VE® { F Wt SUBSURFACE SEWAGE.DISPO SAL SYSTEMO PART A'. . CERTIFICATION• APR 2 _9 2002 TOWN OF BARNSTABLE Property Address:. HEALTH DEPT. r d i v Owner's Na me ^ G� Owner's Address: 0 A- (�S"5 . Date of Inspection: `� I Name o.f.Inspector: (please rint) Company Name, MAP ®� Mailing Address: ° PARCEL • Telephone Number: ,-7"7 LOT (0 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 ply per function and maintenance of.on site sewage disposal systems. I.am a DEPtraining and.experience in the pro approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000):: The system: Passes. �. ConditionallyI asses 'r Needs.Further Evaluation by the Local Approving-Authority gal 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. age I Title 5 Inspection Form 6/15/2000 p ... Page 2 of 11 , OFFICIAL INSPECTION FORM—NOT'FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART A / CERTIFICATION (continued) Prope'rtyAddressi,6?.., AJ Owner::" .:Date of Inspection: inspection,Summar : Check y A,B,C,D or E%ALWAYS complete.all'of Section`D A. ystem Passes: I have not found any information whtch.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: more S st m components as described ' '.'y p b to the Conditional Pass section need to be re laced or A� p re aired. The "si ,pon completion of the replacement or repair,as approved by the Board of Health,will pass. To-j 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 inft.ltration or exftltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as'approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation"of sewage backup`or breakout or high static water level in the distributionboxdue to broken or obstructed pipes)or. due to a broken: settled or uneven distribution boz System will`pass`inspecEiorr if(with" approval:of Board of Health): broken pipes)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 - Page 3 of 1'1 OFFICIAL.INSPECTION FORM- NOT FOR-VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM:INSPECTION FORM ..PART A CERTIFICATION(continued) Property Address: Owner: Date of Inspection: /Ir. , 1?60o7 C. Further Evaluation is Required by the Board of Health: Conditions.exist which require further.evaluation,by the Board of Health in order-to.determine,if the system is failing to protect public health, safety or the environment: 1. System will,pass;unless Board of Health determines in accordance With:M01 CMR 15:3.03(1)(b) hat the system is not functioning in a manner which.will protect public'health,.safety andalie environment:_ Cesspool or privy is within 50 feet of a.surface.water `_ _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water.Supplier,if any)determines that the. system is.functioning in a.manner.that protects the.public health;safety and,environmentc _ .The system,has.a septic tank and-soil absorption system(SAS)and the SAS is.within.1.00 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 aseptic tank..and SAS and the SAS.is within 50 feet of a private water.supplywell. _ The system has a septictank: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 poiiution 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 inust:be'attached to.this form:.:. 3. Other.: 3 'I Page 4 of 11 - OFFICIAL:INSPECTION FORM` :._.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE'DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) PropertyAddress: MA Date of Inspection: i D. System Failure Criteria applicable to all.systemr s:, `You must indicate`°yes"or"no".to.each of the'.:following for all inspections: Yes N Backup:ofsewage into.facility or system component due to overloaded.or clogged SAS or cesspool _ Discharge or ponding of effluent to the surface of the,-round or surface waters due to an overloaded or l clogged SAS or cesspool t/ Static li uid level in the distribution box above outlet invert due to an overloaded g_ q or clogged SAS or cesspool.,:: Liquid depth to cesspool is less than 6"below invert or available volume is less than day flow _ V Required pumping more than 4 times,in.the last year NOT due to clogged or obstructed P iP e(s).Number J of times pumped _ t/ Any portion ofthe.SAS, cesspool or privy is below high ground water elevation.. Any.port on 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 l 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 Tess 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 thepresence 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 correcfthe failure. E. Large Systems: To be considered a large`systettithe system .must serve a facility with a'design flow of 10;000.gpd to45,000 , god. 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) ti yes no _ — the system is within 400 feet ofa 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. • ,4 Page 5 of 1.I OFFICIAL INSPECTION FORM.-:NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION'.FORM PART B' CI3ECKLIST.., :,. Property Address: Owner: Date of Inspection: Check if the following have been done.You niust indicate"yes"or"iio'.': as to each of the following Yes No s�_ 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 v fHas the system received normal flows in the previous two week period Have large.volumes of water been introduced to;the system recently or as part of this inspection? Were.as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility.or dwelling inspected for signs of sewage back up'' _ V" Was the site inspected for signs of breakout? _ Were all system components,.excluding the S.ASi.located on site? V_ _ Were the septic tank manholes uncovered,.opene.d,and.the interior of the tank inspected for the condition of the baffles or tees,material of construction, dimensions ;depth of.:liquid,depth.of sludge and.depth of scum?. 'Was.the facility owner(and occupants.if different from owner).pro.vided with information on the proper maintenance of subsurface sewage disposal systems 7 The size and location of the Soil Absorption System(SAS)On the site has been determined based on: Yes no V _ Existing information. For example;a plan at tl�e 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)) 5 Page of I] OFFICIAL INSPECTION rORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE-DISPOSAL SYSTEM INSPECTION FORM PART C ' SYSTEM INFORMATION kO Property Address: Owner:: Date'oflnspection: FLOW CONDITIONS RESIDENTIAL ✓ ��// Number of bedrooms(design): Number of.bedrooms(actual):. T. DESIGN flow based'on 310 CMR 15.203 (for example: I l:0'gpd x#of bedrooms):} -Number of current residents: Does residence have.a garbage grinder(yes or.no)�—G Is,laundry on a separate sewage system (yes or no [if yes:separate inspection repuired] Laundry system inspected(yes or no)�(� Seasonal use:(yes or no)�(,8-- . Water meter readings, if available(last 2 years usage(gpd)):AO .33 UV el.3 �i0d Sump Pump(Yes or no) Last date of occupancy L•. OOMMERCIAL%INDUSTRIAL.;460, ', Type of establishment Design flow.(based M 3l0 CMR.15.203):. gpd Basis of des ign (seats/person"s%sgftete;): . Grease trap present(yes or no): Industrial.waste holdinglank 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 Wass stem.pumped art of ins ectlon. es or no Y P as P P P (Y ) D` If yes,volume pumped;, gallons How was quantity pumped determined? Reason'for :pumpmg : 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) Inn ovative%Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained froth system owner) _Tight tank _Attach:a copy:of the pEP;Approval Other(describe): pproxim. of age' f all co onen , date i stalled(if known)and,source of information: Weresewage odors'defected when arriving of the site(yes or no): ((J-- 6 f Page 7 of t f OFFICIAL INSPECTION FORM=.NOT FOR:VOLUNTARY-ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION;FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner•. "4 Date of Inspection:. 07 BUILDING SEWER(locate on site plan)<� {;q- 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: �10ocate.on site plan) Depth below grad Material of construction: vdoncrete metal. fiberglass Polyethylene _other(explain) If tank is metal list age:_ 1s age confirmed by a Certificate of Compliance(yes or no): (attach a copy_of certificate')' Dimensions:/CO,5'.>r Sludge depth: Distance from top of sludge to.bottom of outlet tee or baffle: Scum thickness: / r .�>. 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:, kzhwi,ry Comments(on pumping recommend ions; inlet and outlet tee or baffle condition;structural integrity, liquid.levels related to outlet invert,evidence of leakage,etc): O &qM Qalkk&'M ,,axj .. 9;R ,c GREASE TRAP 41.ocate.on:site plan) Depth below grade: Material of construction:_concrete metal_fiberglass__polyethylene,_other (explain): Dimensions: VW ow) 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 I 1 OFFICIAL INSPECTION FORM=;NOT FOR VOLUNTARYASSESSMENTS SUBSURFACE`SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C :SYSTEl! JNFORMATION(continued) Property Address; 1. ` Owner:. Date of Inspection TIGHT or HOLDING TANK. in be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction:..: : concrete metal fiberglass ._polyethylene` other(explain): Dimensions: Capacity: gallons Design Flow:, gallons/day Alarm present(yes or no): Alarm level: . Alarm in working order(yes or no): Date of last'purn i Comments(condition of alarm and float:switches, etc,): i DISTRIBUTION BOX: . V (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.): i PUMP CHAMBER%G='�(locate on site plan) Pumps in working order(yes or no) Alarms in working order(yes or no):. Comments(note coridition of pump chamber;condition of pumps and appurtenances,etc.).' 8 Page 9 of I I • OFFICIAL INSPECTION. FORM-.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ..SYSTEM INFORMATION(continued) Property Address:. Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): �ocate on site plan,excavation not,required) If SAS not located:explain why:: Type eaching.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,_ )./ CESSPOOLS;."(eesspool 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.): ` PRIVX, (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.): I 9 . Page 10 of 11 _ OFFICIAL INSPECTION.FORM-,NOT FOR-VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PA-RTC SYSTEM INFORMATION(continued) Property Address:. .�1C.1/� . Owner: . �.� Date of Ins ection: P E� 01 SKETCH OF SEWAGE DISPOSAL SY„STEM Provide a sketch of the sewage disposal system including ties to at least two permanent'refere:nce landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building, 9 / C 10 Page 11 of I 1 OFFICIAL- INSPECTION-FORM—NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) \ R Property Address: / P Owner: Date of Inspection: a- 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,.daie of.design plan reviewed Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Boar'of Health-explain: hecked with local excavators, installers (attach documentation) Accessed USGS database-explain; You must describe how you established the high ground water elevation: 11 Permit Number: Date: • Completed by:. HIGH GROUND-WATER LEVEL COMPUTATION Site Location:_ ] ZZ ��/.��C'e Lot No. Owner: k('/' Add.ress- Contractor: Address: J221" Notes: STEP 1 . Measure depth.to.water table tonearest.1/10.t............................................. Date month/day%yeas STEP 2 Using.Water-Level.Range Zone and ln.de.x WeII::M.ap.locate site an.d•determine: OAppro.priate.index well-...................... � O Water level range zone- ................... ............ STEP. :3:: Using month ly.repor-t,.''Current :.. . . Water Resources Conditions" determine current depth to water level for index well ............................ month/year I . STEP. 4. Using Table.o.f•WaterJevel Adjustments • for index well (STEP 2A),.current depth to water level for index wel.l (STEP 3), and water-level zone (STEP213) determine water level adjustment .................................,..:........................................:....... ...... ,. ST.E,P;. 5 stimate depth to,high water by subtracting the water level adjustment..(STEP 4) from measu.red-.depth to water � . levelat site.(STEP 1) ................................................................................................................. /J� Figure 13:--Reproducible Computation iorm; �J 1eac-1hy x or/ LOCATION ,s r pSEWAGE PERMIT NO. Erb � �F 144.,,Aiha ��yf l►col VILLAGE /�a.s� -mu/f INSTA LLER'S NAME i ADDRESS JOHN A. AALTO BACKHOE SERVICE ISO wmintit Street West Barnstable,, Mass. 02668 e U I L D E R OR OWNER r - ©I cri DATE PERMIT ISSUED : � � ` � DAT E COMPLIANCE ISSUED r i �� � / 1 S ' `. � � �� � X c.�. � _ � ��_ � r __..v.:; No... �—...../.5" Fps... :— -._... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ................OF....... {�5� .......---.................--- ApplirFa#ion for Dispm al Works.Tontrnrtion rnmit Application is hereby made for a Permit to Construct (V_�or Repair ( } an Individual Sewage Disposal System at: ............................................................ ... .......................................... Location-Address or Lot No. ..................... FO.. o Co i U c% /n ..... ............ E --••--...---•--. a . .. ... ! [.: O �.I.L— ie[.... �dress Installer Address d Type of Building Size Lot_��_ f....Sq. feet aDwelling—No. of Bedrooms----.._.. __________________ --.-Expansion Attic ( ) Garbage Grinder (✓S p, Other—Type of Building ------Need ..... No. of`persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ._._. W Design F1oAtl x 3.=33Q_..IXbII...........gallons per person per day. Total daily flow--------11f .......................gallons. WSeptic Tank—Liquid capacity/NbO..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 (i/f Dosing tank ( ) '~ Percolation Test Results Performed by -.---.-A?Xl�f:.................;f........._-_.......... Date...AFItR7.6................ Test Pit No. l....A--------minutes per inch Depth of Test Pit---- �--...--.. Depth to ground water-----A"S....... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ . . . . . . O sirvb. --4 3 Description of Soil---�.Afl�__�_at,2SSc�L4a....�,..:�:--•----y --��------------------------------------------------------------------------------------- U --------------•---••-------•-------•--CL,E�iU----•��:----5�iv :---.........----------...--•----------------------------•------•-------•------•------...-------------•-- W •••••----•-•--•--------------•...-•-•--------......••---------•---•••-•------------........_...---•---•-------------------------•••---••--•-•-•-•------•------•--•-----------••----------•---••-----•-- UNature 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 iITI1Z 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has lbeeeno iisssu by the bo th- ... - ----------i;�i ... ........ Application Approved BY = Pa Jl -s--..._ Dat Application Disapproved for the following reasons________________________________________________________________________________________________________________ ......................•------•-------•-.....----•-----------•-------•---•-----•---...........------------._......_...---•--------•-------•-••-----•------------------................................... Date Permit No.._ j............................................. .. Issued....................................................... Date "Fxs.. . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH - ce>�cJ OF , . 1 ,Apure#ion for Disposal Works Tonstrurtion Vrrmit Application is hereby made for a Permit to Construct (✓) or Repair ( ) an Individual Sewage Disposal System at: ................•---••--•-1�0 ...• _.................... -- •• ---------------------------............. Location-Address or Lot No. ....�?.:-�=---_.�. �-�`� �:` - ....43 ® -e nests. ............ ...... .............. O ner Address -----••�®L ......-� Z ..-------•------•-----•--•------ C'�_...�-!....ev c� /l! --------•------------•---- � Installer Address Type of Building Size Lot. .5a Sq. feet Dwelling—No. of Bedrooms............13............................Expansion Attic ( ) Garbage Grinder (� '4 Other—Type of Building A." No. of persons............................ Showers — Cafeteria QI Other fixtures ....._..__.. d ----------------------------------------------------------------------------•---••-----••-----------------.--..------•---- Desi n Flow. \a x 3..=33c�-• ,6- !V .................. W g _..gallons per person per day. Total daily flow___________________ _ gallons. WSeptic Tank—Liquid capacity/SC.O.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 ( V1 Dosing tank ( ) F" Percolation Test Results Performed bi.BA .................. 1........._........_.. Date_Z4 a7 I W a Test Pit No. I..... Z......minutes per inch Depth of Test Pit...._ ....... Depth to ground water........UVOG s ..... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....................... Rr' Description of Soil...... I`, i 4'�� ------...*.L --•--(zL Y--- ---•------•----------------••-------------------------•-••----•--••--- x ......•-•-•• it1--• .... .:..........---•-•---•-••---•-••-•-------•-•--•-•-••-••-------••...............•------••••---•----- V W x •--•---•-•------ ----------•-•-----•------••----•---•----•-•--------•-----------•-----•••---•---••--------------•--------•--•--•-•------•--•---•-----•------••••----•----••---------••---••-••-•--...... 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 I'1% 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issue3l by the board of health. 'fined... ...�..�� .. - ate Application Approved BY °�- :} - ! `7PS...-- Da Application Disapproved for the following reasons:................................................................................................................ •-------••-•......---•---•---------------•------------------......-----:...---------...----•---------•-----------------------•---•---•---•••-•--•-----•-------•-••--••------•--•-------••----•....._.... j'jjr 4,Y'5,_ Date PermitNo.......................................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............OF......�i�!�/C,�% � ................... y' = TrrtifirFatr of Toutpltanrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( Repaired ( ) b bY------- ......_.. at........... R(••..... �?!^ icv ---. Installer� ------M-fn.................................................................. has been installed in accordance wrt I ... -sions of TITLE 5 of The State Sanitary Code as des ribed in the application for Disposal Works Construction Permit No..___..___ _-. ._ ��__. dated-------e-�: `"' THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CON TRUE® AS A BJAR'ANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE------••-••-••--_-•..`�•- .� - _............................... Inspector............. --------••-•--•-..... ................................ ....... THE COMMO�NWEAL-TH`_OF.MASSACHUSETTS Af , BOARD/� OF HEALTH :/.".wN............OF....!cJ� /.-1.T.- / FEE .. No.` :.. Dispos a1 Works Tons#rudion rrutit Permission is hereby granted........... ......f6 ---------•--------•---------------•--•-------=-------••---•--•------..........--•-•--- to Construct or-Repair ( ) an In -vidualy S-cw� Disposal System w — Street as shown on the application for Disposal Works Construction Permit No--- -------- bated_______________ ---- .................... Board of Health DATE................................................................................ FORM 1255 A. M. SULKIN, INC.. BOSTON 4A S//✓ALE ,cAMI L-Y = 3 BE-D2ooM wIT-H 6-AK3A6-E- 61ZWDER w� DA1 L'Y Flow no x 3 -330 (so/) _ qSG.P. D. SEPTIC TAQK = 330 x 2007, = 6(>o G.PD. USE 1500 GAL-TANK, DISPOSAL PiT- v5E loon. �UAl__�W 2 'Sro�►� - o+ ,. t — ti 51.DEWAL_L- A PC-A = 16g S.P, ' lot LOT 02.1� 88 K Zs = 4-7o 6<Po. Z9 524 EQ,F7- 00-MoM AREA = 79 S. P. g3' 79 _x /, 0 - -7 9 G.P. D. I ro-rAL DES)64\;' = 5-4(1 GP. D. TbTA L DA I Ly Vlow 49 S- G.P.oD. IOo 3,` log " DE 516 AY . P C2 C.c>>-ATl u N P ATC ` Pew Po s kro _ o M I k), c'R. L.G SS \ r,R,��,SAY S\ bW e-Lu Q 6- 41 OF M,q3�, c,9 ��. 0 91 PETER -SULLIVAN VVILLIAfdI No 29733 N Y E N 19334 o 1 1 A D G►STEP+ Eti <�.F.` TE�� �gNAt EN ,\ 'J v�y _1 qY•7_t 2S_no a, pAJLsrt o\jc- 2vA c> 9 r� G G Fozo ,SULL%vA,v \ap��Cs 4 813 IZ1z�1c) s��7'y l�Easfo sauu�( ��.• oisr. l50 0 /� •.•. GL.aY , /000 BOX /N✓ GAL, 3� cZ. /�✓ 97 9�8 - 97a s,E�c o. LLgG4 o ]r�On/JC rH 2' -- /it/✓. /Nd 3/u lh� r7'z g .4 G•,E2T/F/EO GOT pL4A✓ y STo�JE �C ;/l.O ,jGGL� /'/- ro0 �.4TE /y9 -L �No w� iZ P�J�ost; l�/ gv l3cac�L 3Sy �/-�G� 9Z / GE' ♦ y 7f/.4TTNT' PWC- U1AJ6- L07' e6 �/EC�Ea v G'�MPLY�S W17-11 -4A1,0.fEr.9AG` d,' 77,14 ,eEGisr�'ec'O.GQi✓o-Sli.2ciEya,P� TOx/.v of g,�}JZIJsTL}I3 L� Q.v� /.S NOT G�ST�.21�/LGc a �l.�s.�. 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