Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
0052 WOODSIDE ROAD - Health
52 Woodside Road Marstons Mills A = 127 - 016 J J� 0""V'te OWN OF BARNSTABLE LOCATION SEWAGE# VILLAGE -Maf5b�3S� &i/1 ASSESSOR'S MAP&PARCEL INS NAME&PHONE NO. �JN\y[e 4"S- -7 SEPTIC TANK CAPACITY /5-00 LEACHING FACILITY:(type) vZ- WJl�orva_ (size) Mo-0 NO.OF BEDROOMS 6 L116erwiS 6, (� , OWNJER DATE: ',—J Vi COMPLIANCE DATE: Separation Distance Between the: t Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility \y Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) L a Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) ' Feet FURNISHED BY�t��v, Ir A 1-30' B 1-24' W 2-34' 2-21' p 3-54' 3-21'r .. .0 452'-� 4-32', r w C - '_'5=37' S-37' 52 Woodside Dr h W, Barnstable, MA 02668 5 6' (R=6') Leachpit Rear of HouseLB w/ 3' stone A 4 1500 Gallon O Septic Tank 1 2 D-Box 6' (R=6') Leachp t. --- w/ 3' stone a.: Commonwealth of Massachusetts . Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated 6/16/2000. Inspection forms may not be altered in any way. A. Certification Important:When filling out forms 1. Property Information: on the computer, use only the tab 52 Woodside,�,, RO @ key to move your Property Address cursor-do not Scott Leroux use the return key. Owner's Name 52 Woodside Dr Owner's Address arston_M_ ill /West-Bar s4able MA 02648/02668 _ C' fro State Zip Code Date of Inspection: 06/29/07 Date 2. Inspector: 3". Mike Hudson Name of Inspector Septic-wiz Environmental Services Company Name 31 Midway Dr Company Address Centerville MA__ 02632 City/Town State _ Zip Code 508-367-5669 Telephone Number 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 maintenande of on-site sewage disposal systems. I am a DEP approved system inspector pursuant to section-4346ef Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails rQ_D CID ❑ Nee5eFurther Ev ation by the Local Approving Authority �= 07/05/07 E3 l Insp lei Signatu . Date c o rn r The system inspector shall submit a copy of this inspection report to the Appr ving 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. ****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. 52 Woodside Dr-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 16 Commonwealth of Massachusetts . Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M A. Certification (cont.) 52 Woodside Dr Property Address W. Barnstable MA 02668 City/Town State Zip Code Leroux 06/29/07 Owner's Name Date of Inspection Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 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: Mailing address is West Barnstable, actuall property address is Marstons Mills. 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 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: 52 Woodside Dr-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 16 Commonwealth of Massachusetts Title 5 Official ,inspection Form ° Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 52 Woodside Dr Property Address W. Barnstable MA 02668 Cityrrown State Zip Code Leroux _ 06/29/07 Owner's Name Date of Inspection �( B) System Conditionally Passes (cont.): I- ❑ 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: C) Further Evaluation is Required by the Board of Health: �1r ❑ 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 52 Woodside Dr-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 52 Woodside Dr Property Address W. Barnstable _ MA 02668 City/Town State Zip Code Leroux 06/29/07 Owner's Name. Date of Inspection C) Further Evaluation is Required by the Board of Health (cost.): 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 I 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: 52 Woodside Dr-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 16 f Commonwealth of Massachusetts Title 5 Official ,Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 52 Woodside Dr Property Address W. Barnstable MA 02668 Cityrrown State ZipCode Leroux _ 06/29/07 Owner's Name 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 No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool � ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or 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 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. 52 Woodside Dr-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 I Commonwealth of Massachusetts Title 5 -Official ,Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 52 Woodside Dr Property Address W. Barnstable _ MA 02668 City/Town State Zip Code Leroux 06/29/07 Owner's Name Date of Inspection 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. For large systems,.you must indicate either"yes"or"no" to each of the following, in addition.to the questions in Section D. 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. 52 Woodside Dr-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M B. Checklist 52 Woodside Dr Propery Address W. Barnstable _ MA 02668 Cityrrown State Zip Code Leroux 06/29/07 Owners Name Date of Inspection Check if the following have been done. You must indicate"yes"or"no"as to each of the following: YES NO ® ❑ 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? ® ❑ 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? ® ❑ 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 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: ® ❑ 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)] 52 Woodside Dr-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 7 of 16 Commonwealth of Massachusetts Title 5 Official, Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information 52 Woodside Dr Property Address W. Barnstable MA 02668 City/Town State Zip Code Leroux 06/29/07 Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 5 (1 an office) DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 3 — Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage 2005-244 GPD 9 ( y g (gpd))' 2006-184 GPD Sump pump? ® Yes ❑ No Last date of occupancy: occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 52 Woodside Dr-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 16 Commonwealth of Massachusetts Title 5 Official, Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 52 Woodside Dr Property Address W. Barnstable MA 02668 _ City/Town State Zip Code Leroux 06/29/07 Owner's Name D f Date o Inspection General Information Pumping Records: Source of information: Home owner- Last pumping June 2004 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: N/A gallons How was quantity pumped determined? N/A Reason for pumping: N/A Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 21 years, installed.in fall of 1986 via disposal permt ofieBraeO Were sewage odors detected when arriving at the site? ❑ Yes ® No 52 Woodside Dr-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 Commonwealth of Massachusetts Title 5 Official ,inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information (cont.) 52 Woodside Dr Property Address — W. Banstable _ MA 02668 _ City/Tow-i i State Zip Code Leroux _ 06/29/07 Owner's Name Date of Inspection Building Sewer(locate on site plan): Depth below grade: 33"feet Materia'of construction: ❑ cast iiron ®40 PVC ❑ other(explain): - — Distance from private water supply well or suction line: feet Commeits (on condition of joints, venting, evidence of leakage, etc.): Septic bank(locate on site plan): Depth below grade: 21 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of El Yes ® No certificate) Dimensions: 5'8"Wx10'6"Lx5'8"H-1500 gallon_ Sludge depth: 4'6" (6'thickness) Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 1/4" Distance from top of scum to top of outlet tee or baffle 12" 14" Distance from bottom of scum to bottom of outlet tee or baffle — How werel dimensions determined? measured stick w flapper, tape, spot light, mirror 52 Woodside Dr-T5 Inspection.doc-11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 16 L Commonwealth of Massachusetts Title 5 Official, Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 52 Woodside Dr Property Address --- -- —V--��--- -- --- W. Barnstable _ __ MA 02668 _ Cityrrown State Zip Code Leroux 06/29/07 Owner's Name Date of Inspection 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 pumping every 3 years, inlet tee in good condition, top of outlet baffle in poor condition but working, tank appears structurally sound liquid levels normal at inverts, no evidence of leakage. ' Grease Trap(locate on site plan): Depth below grade: P feet 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: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: - Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 52 Woodside Dr-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 16 Commonwealth of Massachusetts Title 5 Official, Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Farm M C. System Information (cont.) 52 Woodside Dr _ Property Address W. Barnstable MA_ 02668 Cityrrown State Zip Code Leroux _ 06/29/07 Owner's Name Date of Inspection Tight or Holding Tank(cont.) Dimensions: -- Capacity: -- gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: -- Alarm in working order: ❑ Yes❑ No Date of last pumping: Date -- 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 even w/ Inv out 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.): d-box level, no solids or evidence of leakage in or out. Replaced cracked cover. Pump Chamber(locate on site plan): Pumps In working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 52 Woodside Dr-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 16 Commonwealth of Massachusetts Title 5 Official, Inspection Form Not for Voluntary.Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 52 Woodside Dr Property Address — — — W. Barnstable _ __ MA 02668 City/Town State Zip Code Leroux _ _ 06/29/07 Owner's Name Date of Inspection Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 2 1000 gallm ❑ 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.): 2 Pits, 6' radius w/3' stone around, soil dry, very compact hardpan mixed w/rocks, gravel, silt and sand, no signs of hydraulic failure, no ponding. Stain line in pit(1) 7" below inlet invert w/liquid depth 4.5'W/bottom of SAS 132" below grade. Stain line in pit(2)6" below inlet invert, liquid depth 4.5' and, bottom of SAS at 144"below grade. 52 Woodside Dr-T5 Inspection.doc 4 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 i Commonwealth of Massachusetts Title 5 Official ,inspection Form -- Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) — 52 Woodside Dr Property Address �----- ----- -- ----W. Barnstable MA _ 02668 City/Town State Zip Code Leroux 06/29/07 Owners Name Date of Inspection 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 ❑ 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.): 52 Woodside Dr-T5 Inspection.doc•11/2004 Title 5 Official inspection Form:Subsurface Sewage Disposal System Page 14 of 16, Commonwealth of Massachusetts Title 5 Official ,Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form G. System Information (cont.) 52 Woodside Dr Property Address --- W. Barnstable _ MA 02668 _ Cityrrown State Zip Code Leroux _ 06/29/07 Owner's Name Date of Inspection 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. W A 1-30' B 1-24' W 2-34' 2-21' 3-54' 3-21' C 4-52' 4-32' C 5-37' 5-37' 52 Woodside Dr W, Barnstable, MA 02668 5 O 6' (R=6') Leachpit Rear of House w/ 3' stone A B 4 3 1500 Gallon O O O Septic Tank 1 2 D-Box 6' (R=6') Leachp t w/ 3' stone 52 Woodside Dr-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 16 Commonwealth of Massachusetts T , r - , Title 5 Official, Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 52 Woodside Dr Property Address — --___--�__^------_--- - W. Barnstable _ MA 02668 Cityrrown — State Zip Code Leroux _ _ 06/29/07 Owner's Name Date of Inspection Site Exam: Slope j 9 Surface water 0� Check cellar e Shallow wells Estimated depth to ground water: r Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date.of design plan reviewed: 07/05/07 _ Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: reviewed as-built, construction ❑ Checked with local excavators, installers- (attach documentation) ® Accessed USGS database-explain: Reviwed USGS topographic and water resource maps _v You must describe how you established the high ground water elevation: reviewed system design plan and perc test by Arnie Ojala of Down Cape Engineering dated 12/17/84, reviewed as-built plan and disposal construction permit, reviewed USGS topographic and water resource maps as well as google earth satelite maps. -? mrc t— — -- -- 52 Woodside Dr-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 TOWN OF BARNSTABLE LOCATION ® ��� k SWAGE VILLAGE ASSESSOR'S MA Cz LOT/,,��;I— INSTALLER'S NAME & PHONE NO. 7d SEPTIC TANK CAPACITY !� LEACHING FACILITY:(type) / (size) �JGu NO.�OF BEDROOMS PRIVATE WELL OR PUBLIC WATERA� 'BUILDER OR OWNER { QDL�DC DATE#PERMIT ISSUED:_ 01�7A DATE .COMPLIANCE ISSUED: ?��< VARIANCE GRANTED: Yes 4 No CO ISSESSORS MAP NO: PARCEL NO.: _�O <Z:2 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............ v...........OF.... Appliration for Dhqpoiial Works Tongtrudion runfit Application is hereby made for a Permit to Construct or Repair ( 4-f-11. Individual Sewage Disposal System at: Veation-Address . ... ...... iu..... ........................ or Lot No. ....... ................................................................................................. Address ............................................... .................................................................................................. ......�,-7_� �wx-------- W Installer Address Type of Building Size Lot............................Sq. feet U Dwelling No. of Bedrooms--------------------------------------------Expansion Attic Garbage Grinder Other—Type of Building ............................ No. of persons.:.......................... Showers Cafeteria Otherfixtures .........................------------------------------------------------------------------------------------------------------------------------- Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 1:4 Septic Tank—Liquid capacity............gallons Length................ Width.........__.__.. Diameter-_______-__-_- Depth_............... Disposal Trench—No.....................Width_..._.....__._._._.. Total Length............._...._. Total leaching area..........---------sq. f t. Seepage Pit No_____________________ Diameter-___-___-_.-_._----- Depth below inlet.............._..... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by..-- ..................................................................... Date.................. -------------------- Test Pit No. I................minutes per inch Depth of Test Pit...._.._............ Depth to ground water---------------------- 44 Test Pit No. 2................4nmut s per inch Depth of Test Pit...___._...._..._... Depth to ground water......_____........._... . .... . ..... ............ .... ..... ................................................................................................... 0 Description of Soil..................... ...... ..... W U ........................................................... ................................................................................ -------------------------I................................................................................................. ---------------------------*------------------ 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 TL IL Ti LZ 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issued by/fihe b ar health. Si ned- . ...... ApplicationApproved By.................. .......... .... ..I... .......... .. ..................... -------- Date Application Disapproved for the following reasons:.............................................................................................................. ........................................................................................................................................................................................................ Date Permit No........ ... ......I V -01.... Issued....................................................... J0-11--I Date � `� �� `� �• t._ -- •.7 1,_, m { . ,1 � ti � . ,, I .. �/ _ '� '2': �) S ��`�R�'?: w. � it `,`~� �. • •� �' t� d No....:...........�..v 9 Fps... .......... THE COMMONWEALTH OF MASSACHUSETTS , BOAR® OF HEALTH ..----- -- f-�%� -..........oF.. ................................. Appliration for Disposal Works Tonstrnrtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair (A-100an Individual Sewage Disposal System at• ���/��- ....` .. .. . 3° --•----------------- ---------------------•---•..._......-••-•-. -•--•---------.._...................----•- ---Coca'on-Add es -••---.---- ----•-------.--.or Lot No. .......� -?�' -.�-�, Q.�„� --------------------------------- ----------- wr. • 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 Q' Other fixtures -•-------------------------••••. • . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ 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........................ (i Test Pit No. 2................nimu s per inch Depth of Test Pit.................... Depth to ground water........................ 9 -------• -• -- ---- ------- ----------- -- DDescription of Soil------------------- .. ......-----•------•--------------------•--•--------------------------------------------------------------•- x UNature of Repairs or Alterations—Answer when applicable.______ _�d -Z .................................................. --------------------------------•---------------------------------------------------........--•--•••-•.................--4' i Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T 1 T iE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has�bi b the a f health. Signe . / 7 }t'1 ae Application Approved By--•-------•--•.............. - - Date Application Disapproved.for the following reasons:---.•-------------•--------------------------------------------------•----------•----------------------------- --•-•••--•--••••--•-•---•--•-•-•-••--•••-....._...•-----•-•-------••--•••----•-•.............•------•-•--••---------•---•-•---••-------•••------•-•••--•••-•••--••••-•••-•--•-•---••-•-•••--•-•-...-•--- Date Permit No...... ------14 4-- ---_ Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEA .........�d.-lJ..� ........OF.......... ...:.W.. .......... Trrfifiratr of ToutlifiFanr T,_iS T�jC RTIFY h the Individual Sewage Disposal System constructed ( ) or Repaired bY----LJr `'! D _ ��J� � ---------------------------------------------------•----------------------------.........--------------------------------- at.--• �� 5� �6 A' Installer -------•--------------- ILTI has been installed in accordance with the provisions of TE 5 of The State Sanitary Code as escribed in the application for Disposal Works Construction Permit No.�,__ l"__•__-_0_fl_ct_...... dated----- p�_'�_. ................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE ...�"1. 0t� 4� Inspector THE COMMONWEALTH OF MASSACHUSETTS BOARD 9F HEALT Tl-�---. (I�.Lf? .......e..-1..�/.0.............OF.............l�iil.�c�/3'L... .....-'�........................... ..... Dispos. � un ion amit Permission is hereby granted......�L/I • � -J to Construct ( ) o pair ( an IV'du Seta Disposal System Street as shown on the application for Disposal Works Construction Permit No _?.. ... Dated_�.__..�__.��-� CMG------- Board of Health DATE--------- --------------------------------------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS y I, r 1 t • t ` i '-S/TE �i PLAN t -SHEET l of 2 f SCALE: l 40' N Sze 33 40" 421- r V, f� J.) \ 'N pi, X. \ \ 0 O N � o, e(o ti7 bi SLOT L o -i- - a r2 g 7� r i w ovate I nr ------------ 4 aF • Oi S - �o WILLIAM y, c M. u �&1RWICK No. 19TI i / • '��L TANG�;�- , :. REG/STEREO LAND SURVEYOR F0 R- k Lv ZONE-_ 9 � 13,+.rzr35T`A+3Le M A.���> , PLAN REF_r--, r:�1�4 . DATE -7 I / BENCH MARK'DATUM vM WM. M. WARW/CK 8 ASSOC., INC. DOMESTIC WATER SOURCE"Yp W t-J BOX 60/ - NORTH FAL MOUTH FLOOD ZONE._Nor•,)- 1-\n.�g, y� p G MASS. 02556 - (6/7) 56 3 -26 3B ; 1 Lo T 5l NOW dSNI �( G Foy c rt r�1 PA �( y:,INVI ads 1NV:) \ T S/ f f:�V_r•5 . G G%ri• :%'L'47 RI- 67 OF Mq ` y WILLIAM tiN WARWICIC H o No. 19771 -Q �ss��FGISTER���Qv\`' s. ONAL LANDS On the basis of my knowledge, information and (, r ��� <'jr..--�� belief, I certify to Twn o,� trn61G6/� �-----T lti/• ����_r••.►;-i"��.-i...� ;. Mom!-.!,, that as a result of a survey made on the ground II ` on i5 I find that: ..: The structure(s) are located on the site as j shown. W 1A MI V\/A1�.�!Ic r The title lines and lines or f occupation of the site are as shoi-ni hereon. The site is situated in Flood gone Al,,,? Gr Community Panel No.zSo,�i ceisc. _llate: Date: 1 « e.- ililliam 1-:. ;darwick,ILLS' I Hazardous Materials Inventory Sheet Checklist 1 v Date Physical Street Address-Check database to ensure it exists Working Phone Number Actual-Amounts -( ie. gas being used to fuel machines,thinner to clean brushes all count as hazardous materials-no blanks) t/Storage Information - location of storage, how long is storage for? If none, note that. _ ),,--Disposal Information -where and who? If none, note that. Applicant Signature -understand what is listed and noted Staff Initial-any questions, know who to ask Vehicle Washing/Rinsing? -give a vehicle washing policy and explain it Attach the Business Certificate with your sign off and comments **The inventory form should explain what the business consists of and the procedures they are doing. Notes need to be left to explain what you discussed with them. YOU WISH TO OPEN A BUSINESS? For Your Information: Business Certificates COST $30.00 for 4 years. A Business Certificate ONLY REGISTERS YOUR NAME in the Town (WHICH YOU MUST DO BY M.C.L. - it does not give you permission to operate). You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, I" Fl., 367 Main St., Hyannis, MA 02601(Town Hall) and get the Business Certificate that is required by law. LT; DATE: F Fill in please: APPLICANT'S YOUR NAME: N to BUSINESS YOUR HOME ADDRESS: :mow MR, e,C TELEPHONE # Home Telephone Number: L ` NAME OF NtW BUST' ESS C.P�'1 c% t, G� C c CG; TYPE OF BUSINESS IS THIS A HOME.00CUPATION? _YES NO Have you been given approval from the building divisio ? YES NO . ADDRESS OF BUSINESS 4JO e MAP/PARCEL NUMBER 102 7 When starting a new business there are several things you must do in order to be in compliance with the rules and regulations. of the Town of Barnstable. ,This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING CO SSIO ER'S OFFICE This in di, ual h s b n in#o e I f an permit requir ments that pertain to this type of business. MUST COMPLY WITH HOME OCCUPATION hor' d�Signat e** ____—� RULES AND REGULATIONS. FAILURE TO CommENTS: 1',)--fir n �' t` i u MAY RESULT IN PINES 2. BOARD OF HEALTH This individual h en infor e of he LriItreq uir ents that pertain to this type of business. Authorized nature** MUST COMPLY WITH ALL COMMENTS: HAZARDOUS MATERIALS REGULATIONS 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to.this type of business. Authorized Signature** COMMENTS: Date: TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: BUSINESS LOCATION: INVENTORY MAILING ADDRESS: ©b4" e iQaQ fi TOTAL AMOUNT- TELEPHONE NUMBER: CONTACT PERSON: EMERGENCY CONTACT TELEPHONE NUMBER: ���y2o��`� MSDS ON SITE? TYPE OF BUSINESS: kkX4a INFORMATION/RECOMMENDATIONS: Fire District: AL, 4W k- _f Waste Transportation: ® Last shipment of hazardous.waste: Name of Hauler: & Destination: Waste Product: a Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed/Maximum Observed/Maximum b Antifreeze (for gasoline or coolant systems) Misc. Corrosive NEW USED Cesspool cleaners Automatic transmission fluid 6 Disinfectants Engine and radiator flushes Road Salts (Halite) Hydraulic fluid (including brake fluid) ® Refrigerants 6 Motor Oils © Pesticides NEW USED (insecticides, herbicides, rodenticides) 6 Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil NEW USED Misc. petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink © Degreasers for driveways & garages Wood preservatives (creosote) O Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries C9 Lye or caustic soda 19 Rustproofers 0 Misc. Combustible Car wash detergents 0 Leather dyes 6 Car waxes and polishes b Fertilizers 0 Asphalt & roofing tar © PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, 0 Lacquer thinners (inc. carbon tetrachloride) NEW USED 0 Any other products with "poison" labels Paint &varnish removers, deglossers (including chloroform, formaldehyde, Misc. Flammables hydrochloric acid, other acids) Floor&furniture strippers Other products not listed which you feel Metal polishes may be toxic or hazardous (please list): Laundry soil & stain removers (including bleach) © Spot removers &cleaning fluids n (dry cleaners) U Other cleaning solvents © Bug and tar removers 0 Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS r COMMONWEALTH OF IVIASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION i FRECEIVFnY292001 TOWN OF BARNSTABLE TITLE 5 HEALTH DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 14 Woodside Dr. W Barnstable, MA Owner's Name: Michael Bilodeau Owner's Address: same Date of Inspection: / U Name of Inspector:(please print) Wi 1 1 i am E_ • Robi nson Sr. Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1089 Centerville, MA Telephone Number: (5 0 81 7 7 5-8 7 7 6 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: le Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails, l' Inspector's Signature: iti �ii! /"" 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 1 I Page 2 of l 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued). Property Address: 14 Woodside Dr. W Barnst-ahl e Owner: Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D 2fnotasses: 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. stem 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. Answe yes,no or not determined(Y,N,ND)in the for the following statements.If `not determined please explain. e septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsoun ,exhibits substantial infiltration or.exfiltration or tank failure is imminent.System will pass inspection if the existin tank is replaced with a complying septic tank as approved by the Board of Health. •A me I septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indica g that the tank is less than 20 years old is available. ND a plain: Observation of sewage backup or break out or high static water level in the distribution box due to-broken or obs cted pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with appr val of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND a plain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will ;Nexplain: spection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 14 Woodside Dr. . W Barnstable Owner: Bilodeau Date of Inspection: '�s I O—q I 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 fai ' g 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 ystem 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 sys em 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 fronl 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: 3 Page 4 of I I r OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 14 Woodside Dr. W Barnstable Owner: Bilodeau Date of Inspection: ,S`"la-0 D System Failure Criteria applicable to all systems: Yo must indicate"yes"or"no"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or 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 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. Large Systems: o be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 pd. 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 famed.The owner or operator of arty 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 ' 1 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 14 Woodside nr W BarnstahlP Owner: BiIorlp;; 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 ✓ Were any of the system components pumped out in the previous two weeks? 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? 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 of the baffles or tees,meterial 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 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 CNIR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 14 Woodside Dr_ W Barnstable Owner: BiI odeau Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):j Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms) Number of current residents::— Does residence have a garbage grinder(yes or no): d Is laundry on a separate sewage system(yes or no):/&0 [if yes separate inspection required] Laundry system inspected(yes or no):iL, p Seasonal use:(yes or no): /1,U Water meter readings, if available(last 2 years usage(gpd)): 2000 98, 0000 gal. Sump pump(yes or no):/LU , 2, 0 0 0 gal. Last date of occupancy: C MERCIAIANDUSTRIAL Typ of establishment: Desi n flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Gre a trap present(yes or no):_ Indu trial waste holding tank present(yes or no):_ No sanitary waste discharged to the Title 5 system(yes or no): W er meter readings,if available: L t date of occupancy/use: O HER(describe): GENERAL INFORMATION Pumping Records Source of information: ' Was system pumped as part of the inspection(yes or no): If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYP F SYSTEM YTeptic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: -,4--."-�i e Were sewage odors detected when arriving at the site(yes or no):,a,,.D 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 14 Woodside Dr. W Barnstable Owner: Bi lodeau Date of Inspection: g!6-6 BUI ING SEWER(locate on site plan) Depth b low grade: Materia s of construction:_cast iron _40 PVC_other(explain): Distanc from private water supply well or suction line: Co Pts(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_✓(locate on site plan) Depth below grade: f c� Material of construction: ✓concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) 1 0 Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 2l 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: 6 )rOz L A Comments(on pumping recommendations, inlet and outlet tee or baffle.condition,structural integrity,liquid levels as related to outlet invert,evidence of.leakage,etc.): GREA TRAP:_(locate on site plan) Depth b ow grade:_ Material f construction:_concrete_metal_fiberglass__polyethylene_other (explain) Dimensi ns: Scum t ckness: Distan a from top of scum to top of outlet tee or baffle: Dicta a from bottom of scum to bottom of outlet tee or baffle: Date f last pumping: Co nts(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as rela d to outlet invert,evidence of leakage,etc.): 7 Page 8 of]] OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 14 Woodside Dr. W Rarnst-ahl a Owner: R; 1 ndea„ Date of Inspection: T--1Os0 t T HT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Dept below grade: Mate ial of construction: concrete metal fiberglass_polyethylene other(explain): Dime sions: Capa ity: gallons Desi Flow: gallons/day Al present(yes or no): Al level: Alarm in working order(yes or no): Dat of last pumping: Co ents(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: 6 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 HAMBER: (locate on site plan) Pumps i working order(yes or no): Alarms n working order(yes or no): Comme is(note condition of pump chamber,condition of pumps and appurtenances,etc.): 14 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: 14 Woodside Dr., . W Barnst_ah1P Owner: Bi lodPau Date of Inspection: S—AO"a d SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type 1 ching pits,number:_ ching 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.): d. � CESSP OLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number nd configuration: Depth—t p of liquid to inlet invert: Depth of olids layer: Depth of cum layer: Dimensi ns of cesspool: ivAlateria of construction: Indicat' n of groundwater inflow(yes or no): Comm nts(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensi ns: Depth o solids: Comm nts(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 14 Woodside Dr, W Barnstable Owner: Bi lodeau Date of Inspection: 5 %0-o � 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. I pti �el y �6 �I a . 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: 14 Woodside Dr_ W Barnstable Owner: Bilodeau Date of Inspection: SWLrS o I SITE EXAM Slope Surface water Check cellar Shallow wells 4. Estimated depth to groundwater q,.Y X 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: %L 3 AL1` Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe h 9 w you established the high ground water elevation: 11