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0055 HILLIARD'S HAYWAY - Health
55 Hilliard's Hayway, (W. Barnstable P 136 047 i o , COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DI?,PARTMENT OF ENVIRONMENTAL, PROTECTION JUL 2 9 2003 70i-. AL i3H DEPTABLE TITLE 5 OFFICIAL (INSPECTION FORNI — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTENI FORNI PART A CEVED CERTIFICATION Property Address: SS /�i1 e�r�l �7e l� MA Owner's Name: ��- ► �^ � PARCEL ; o 4�Owner's Address: 11 �f LOT ` Date of Inspection: o / Name of Inspector. (please print) Company Name: iv Gfi� Mailing Address: O 6 Telephone Number. o 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 S n 15.340 of Title 5 (310 CINIR 15.000). The system: Passes Conditionally Passes Needs Further Evaluatio by the Local Approving Authority Fails Inspector's Signature: GL Date: Q ' The system inspector shall submit a copy of this inspection report to the Apprming 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 authorirv. 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. Page 2 of 11 OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: O Inspecticn Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sys�tc Passes: `� I:1a�•e not found any informaaon which indicates that any of the failure criteria described in 310 CNN 15.303 or in 310 CN R 13.304 exist Any failure criteria not evaluated are indicated below. Comments: B. Systzrn Conditionally Passes: /VCne 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 Hcalth,will pass. Answer yes, no or not determined(Y,N,ND)in the for the following statements. If"not determined"please ri:::;i. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, e-dubits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing rank is replaced with a complying septic tank as approved by the Board of Health. *A met-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 In-el 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 pipc(s). The system uill pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: t'age 3 of t 1 OFFICIAL INSPECTION FORINI - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEIy1 INSPECTION FORM PART A r/— `/CERTIF/ICATI/O/ti (continued) Property Address: JJ f7� o�c — Owner: / �Gt f � Date of Inspection: 6-- 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 sz-stem is failing to protect public health, safety or the environment. 1. Svstem will pass unless Board of Health determines in accordance with 310 CNIR 15.303(1)(b) that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or pricy is within 50 feet of a surface water Cesspool or pricy 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 systern is functioning in a manner that protects the public health,safety and environment: The system has a septc tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water suppl}. _ The system has a septic tank and SAS and the SAS is'within a Zone I of a public water supply. a _, 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 faciliry 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 4or1t OFFICIAL INSPECTION FORD[ — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM, PART A CERTIFICATION (continued) Property Address: r Owner: Date of Inspection: p p� D. System Failure Criteria applicable to all systems: You must indicate"yes" or"no" to each of the following for all inspections: Yes h'o ckup 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 logged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or esspool 4/ iquid 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. ZAny portion of cesspool or privy is within 100 feet of a surface%Vater supply or tributary to a surface �vyttcr supply. ; SIAAAnmy Any portion oC a cesspool or privy is within a Zone 1 of a public well. y portion of a cesspool or privy is within 50 feet of a private water supply well. portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water Supply well %ith no acceptable water quality analysis. (This system passes if the well water analysis, m perforc•` DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates u.". ;ne well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than S pp ,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] X�_(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CNa 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what w necessary ill be to correct the failure. E. Large Systems: To be considered a large s.-stem the system must serve 1 facility with a design flow of 10.004) gpd to 15,04)0 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«idiin 400 feet of a surface drinking water suppiv _ 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" u:Section D above the 1--r-C 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 Clot 15.304.The system owner should contact the appropriate regional office of the Department. Page 5ofII OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEIN1 INSPECTION FORM PART B CHECKLIST Property Address: Date of Inspection: r7 Check if the following have been done. You must indicate`des" or"no"as to each of the following: Yes o mping information was provided by the owner, occupant, or Board of Health Were any of the system components pumped out in the previous two weeks -the system received normal flows in the previous v— �} p us 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 g the SAS, located on site Were the septic tank manholes uncovered.opened and the interior of the tank inspected for the condition of the es 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 Rich 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 CNIR 15.302(3)(b)] Pagc 6 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM LYFORINIATION Property Address: / c✓�S A?Cf Lvc, Owner: A/e::n Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): C)- Number of bedrooms (actual): DESIGN flow based on 310 Cry 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: / Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system yes or no): G'7 Jif yes separate inspection required] Laundry system inspected(y;s or no):IVV Seasonal use: (yes or no): /Vd Water meter readings, if available(last 2 years usage(gpd)): Sump Pump(yes or no). Last date of occupancy: CONMERCIALMDUSTRI L Type of establishment: Design flow(based on 310 CNN 13.203): 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 S system(yes or no): _ Water meter readings,if available: Last date of oc.^%pancy/use: OVER c, bc): GENERAL IINFOILNIATION Pumping Records Source ofinformation: /G'o 2 ���c5 e L-�e�— Was system pumped as part of the inspection(yes or no): (7 If yes,volume pumped:_gallons—How was quantity pumped determined' Reason for pumping: 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 anv) _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 componcnus, date install (if shown)and sourctvf information* Were sewage odors detected when arriving at:he site(yes or no): Page 7 of I l OFFICIAL IIlYSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTENJ INSPECTION FORM PART C SYSTEM MFORNIATION(continued) Property Address: Owner: Date of Inspection: G2 BUTLDLYG SEWER Oocate on site plan) Depth below grade: 9/ Materials of construction: v czst iron C' 40 PVC_other(cxplain): Distance ,-Tom private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage, etc.): SEPTIC'TANK:Z Locate Pnsiteplan) Depth be:ow grade: Material of construction: t/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 certificat.) Dimensions: Sludge depth: Distance from top of s�dge to bottom of outlet tee or baffle: Scum thickness: o� Distance from top of scum to top of outlet tee or baflle: Distance from bottom of scum to bottom of outlet tee or baffle: How we-e dimensions determined. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels aelated to outlet invert,evidenpe of leakage, etc.): _ �vti h v90� ./7--C� eel -7 GREASE TRAP: (locate on site plan) Depth below grade:— Material of construction:—concrete metal fiberglass_polyethylene other (explain): — — — Dimensions: Scum thickness: Distance from top of 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 into d levels as related to outlet invert,evidence of leakage, etc.): Zesty' liquid �q 1 f Page 8 0C 1 I . OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSNFENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORINI PART C /fSYSTEM INFORMATION(continued) Property Address: Owner: 1:5:77 � Date of Inspection: p TIGHT or HOLDING TANK �j (/tank must be pumped at time of inspection)(locate on site plan) ) Depth below grade: Material of construction: concrete metal fiberglass_poiye�ylene other(explain): Dimensions: Capacity: g�o� Design Flow: �a'Ions/day Alarm present(yes or no): Alarm level: Alarm in workingorder Date of last pumping: (yes or no): Comments (condition of alarm and float switches, etc.): DISTRLBG"iv`I Eve: �Cpresent must be opened)(Iocate on site plan) Depth of liquid level abov. .. invert v-70,-,� Comments (note if box is lc•.cl ,,;d distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into out of box,etc.): %S PUMP CH INMER (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 appuncnancc etc.): Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYS TEM INFORMATION (continued) Property Addrw: //Gzl f/ /17G Gv Owner. Date of Inspection: ti SOIL ABSORPTION SYSTEM (SAS): (locate on sit e plan,excavation on not required) If SAS not located explain why: Type leaching pits,number. leaching chambers, number. leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool, number. innovativelalternative system Typelnarne of technology: Comments(note ondition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): �r��� -o CESSPOOLS: � (cesspoolmust be pumped as part of trupection)(locste on site plan) Numbcr and configuration: Depth—top of liquid to inlet invert: Geptn 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 LU of L L OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTENI INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: OwOwner. ,;OVY Date of Inspection: 0 SKETCH OF SEWAGE DISPOSAL SYSTEINI 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 buildingFro V- 6)7er I . A� ,.r Page I l of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS • SUBSURFACE SEWAGE DISPOSAL SYSTEIvi INSPECTION FORM PART C SYSTEM INFORA ATION (continued) Property Addctss: /�} is Hc�jL (,vG Owner. Date of Inspection: SITE EXAINI Slope Surface water Check cellar Shallow wells Estimated depth to groundwater l O feet please intte(check) all method:used to determine the high ground water elevation: Ob/tauted from system design plans on record-If checked, date of design plan reviewed: la?=rved site(abutting property/observation hole wi n 150 feet of SAS) hocked with local Board of Health-cxplain: 2 /J Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe ho you s blished the high ground ?c2tgr elevatioa:161 , C/� Y i 9 4 h 1.�a C C ✓ t of To (,��z DO 0j . f o oo 0 r << e 6 r / _ CJ /I j �d J ' U G COMMONWEALTH OF Tv1ASSACH u SETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS - DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 P Y CORE cret.ary fi ARGEO PAUL CELLUCCI b �n , D B''STRUHS Governor Contnusss oner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR PART A CERTIFICATION Property Address: 5 N I LY/q R PS H6V W 14 V Name of Owner L K l LL[-U Coe. �� Address of Owner: I Date of Inspection:3- " lqq 1�j Name of Inspector:(Please Print) Eo(i1�AIe� �, (30USF1ELD 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.0001 i Company Name: _Eacv14 R D C, 13Ot CS F/CLD Mailing Address: ,2 wco /_ VC o(.t%l C /1I# O�S63 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority /F�aiils �/ (; Inspector's Signatur_:_ �C Date: 5_ /"/7 9q The System Inspector shall submit opy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty (30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND,COMMENTS/ o 614tt 0tU SEPTIC- -FAIU K vER V Goo D CON Q(l I ITTC6 SO[ 1D5 6co 64�(ory F OUR Fc)b-r P REc n s-r ' C E140 Y FM ltu�qs dF ( IQUlo l/VS/oL', L)E_k Y GOOD CoV01770k) revised 9/2/98 Page 1of11 pA® Printed on Recycled Paper . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A r CERTIFICATION(continued) Property Address!:�J y/LYg�Dj VW a r Owner: G Ul LSE co Z Date of Inspection: 1171912707 INSPECTION SUMMARY: Ctr, 8, C, or A A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health, will pass. Indicate yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. _ The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced - The-system-required pumping-more-tharl_fou"imes.a year-due to broken,oX—gbstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed i revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: /V&y/yRD'S k111 pl ?V Owner: LU6444:67 COO Date of Inspection: 3_y_,99? C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public:health, safety.and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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. Method-used-to-determine-distance .._._._.__ (approximation not valid). 3) OTHER I revised 9/2/98 Page 3or11 I L SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:S.S 141I ylR,0S .NAy uw v owner: LUGictc con Date of Inspection: D. SYSTEM FAILS: 7 You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged 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 112 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: 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: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: ' x 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 11 of a public water supply well) The owner,or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. ,a' revised 9/2/98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:pe vvo_5 h1141'WO V" Sr Owner:L(JUyLF Cp Z Date of Inspection:3_1/_6 97 Check if the following have been done:You must indicate either "Yes" or "No" as to each of the following: Y No Pumping information was provided 6y the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with NIA. x _ The facility or dwelling was inspected for signs of sewage back-up. /X _ The system does not receive non-sanitary or industrial waste flow. y _ The site was inspected for signs of breakout. _ All system components, a have been located on the site.. X _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: Existing information. For example, Plan at B.O.H. Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) 115.302(3)(b)] _-- --The-facility-owner.(and occupants,rif-different from-owner)..were provided with information on the proper maintenance of SubSurface Disposal Systems. C revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C t. SYSTEM INFORMATION Property Address: H(C R o S NA Uj n Owner: LUCILLE COZ Date of Inspection: 2,C�_IC,C'C/ J I FLOW CONDITIONS RESIDENTIAL: Design flow: �J3V g•p.d./bedroom. Number of bedrooms (design): -5 Number of bedrooms(actual): Total DESIGN flow, Number of current residents: Garbage grinder(yes or :tuo Laundry(separate system) (yes o�iD :Nn: If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use(yes orC):&0— Water meter readings,if available(last two year's usage(gpd): t'h Sump Pump(yes or Q: U0 Last date of occupancy: ST/C O<.CC)P►ED COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: gpd ( Based on 15.203) Basis of design flow 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: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of info"r1�ation: PUmpED �I 11rs to&o System pumped as part of inspection: (yes or fo tP If-yes,volume-pu-mped:_..___._._.....-:gallons....___-_ ,W .__._.._.... . _.__._..__... Reason for pumping: TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records,if any) VA Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other / q . APPROXIMATE AGE of all components, date installed(if known)and source of information: 1 V, Sewage odors detected when arriving at the site: (yes org? revised 9/2/98 Page 6ofII I s' i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 5 I5 �I I LYOR DS HA w 14 V Owner Luouc coz Date of Inspection: BUILDING SEWER: / 1 (Locate on site plan) Depth below grade:_ Material of construction:_cast iron_40 PVC_other(explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage,etc.) SEPTIC TANK:_C (locate on site plan) Depth below grade:/111)0I5 Material of construction:Xconcrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions: /06rlLX5-3 W'X����r/7 Sludge depth:: oua Distance from top of sludge to bottom of outlet tee or baffle: NCKs Scum thickness: I Distance from top of.scum to top of outlet tee or baffle: 8/R/Chf'S Distance from bottom of scum to bottom of outlet tee or_baffle: /rt1Cf�S How dimensions were determined:�XjPE 1"64SYP Comments: (recommendation for pumping condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, 01, evidence of leakage, etc.) `� PLASric A< lN�7- -7 i CO/UCR I ff« OUTLET U679Y l'LEAIU GDOD CDAJ01770 / L/t7ZE SaU05 GREASE TRAP: (locate on site plan) Depth below.grade:_ Material of construction: concrete_metal_Fiberglass _Polyethylene_other(explain) Dimensions: Scum thickness: Distance from top of 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: (recommendation for pumping,condition of.inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) i revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C I SYSTEM INFORMATION(continued) SS -111 yR N�yw'AV Property Address: �� Owner: 60(ju "60Z Date of Inspection: 3 9q TIGHT OR H'OLDING.TANK: (Tank must be.pumped prior to, or 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 Alarm level: Alarm in working order:Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX: (locate on site plan) DTI Depth of liquid level above outlet invertj,�IT�� Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) d/Ue p/PE' /i(/ Otis" /0/,11Le- OuT /110 Sac-IDS - 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.) revised 9/2/98 Page 8of11 V SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ' SYSTEM INFORMATION(continued) Property Address: 55 1 )LY M NRY Wr9 y Owner: L UC I CL� C'O Date of Inspection: 2 _V-Iggq SOIL ABSORPTION SYSTEM(SAS)*y (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: N LE9Cll, P/T leaching pits, number: dtUE y FOOT 6OD q,4GCd leaching chambers,number:_ leaching galleries,number:_ leaching trenches,number,length: leaching fields,number, dimensions:' . overflow cesspool,number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) L EA,C H C i J / Fc?cl /NC 0-F Ll,!Wi i.0& /UEVE/ . — — O'U C R C = 1 2l0� �TAi�tl 4 �� S bti96L CESSPOOLS:_ (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool�eust-be pumped.as_part_pf_inspection)_....-.. 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.) i revised 9/2/98 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM v PART C SYSTEM INFORMATION Icontinued) Property address:SS NlL S'AR 0-S HA Y GuA Owner: C 06 C CO a Date of Inspection:3 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) �s o w 6LL $g' revised 9/2/98 Page 10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C y. SYSTEM INFORMATION(continued) Property Address: 5�,> Nip yH 2�s H.4 V w 4Y Owner: LULPCCE CO2 Date of Inspection: 3,-y'/g9c( NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater 20 Feet Please indicate all She methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USG'S Data Describe how you established the High Groundwater El e at on. (Must be completed) IYIr�/� GIouti0wqR /�✓�P �� r��P revised 9/2/98 Page 11of11 L 0 C A T �0N SEWAGE PERMIT NO. VILLAGE f INSTA LLER'S NAME ' , & ADDRESS �. P c 6 U I L D E R OR OWNER DATE PERMIT ISSUED 9_-�� _• L�/ DAT E COMPLIANCE ISSUED �Afl s l y �1 . w a -- -O/. �p No...... FizB................. .... .THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH W a &V-A5 A lira#ion for Disposal Works Tonstrurtion rani# Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: ..... .......... �1/ ....A ................................. .c�:........................ Locati n- ss ,1or Lot No. _n�A � c.c.,�------------------ ........AF sue_. .. 1 � -_/.-�-----•...---...------ Owner - Address Installer Address Q Type of Building Size Lot__7S_A;.UQ_..Sq. feet V a Dwelling—No. of Bedrooms.••-.---._Z............ Garbage Grinder..-----.•-- Ex ansion Attic p-, Other—Type of Building ____________________________ No, of persons............................ Showers ( ) — Cafeteria ( ) a Other fixtures ---------------------------- a Q --------------------------------- ----------------------•---•--- ...... Design Flow________________________//Q_......__gallons pe per a �. `T� al daily flow____.___-_________-2Z _..._______ Ions. WW .eSwW I " / Septic Tank—Liquid capacity/QQ�gallons Length i th_'lJ�.IQ__.. Diameter________________ Depth_________.__.-- x Disposal Trench—No_____________________ Width......_......._..... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-_________�_____.__ iameter-----/l��__.__ Depth below inlet.!!l!�.___ Total leaching area_4.VL_'�sq. ft. Z Other Distribution box (✓� Dosing"tank ( ) '-' Percolation Test Results Performed Date.......7_/27" 7 Test Pit No. 1...,(y,�_eminutes per inch Depth of Test Pit...../,._-_.._.. Depth to ground water...... L___---------- (i Test Pit No. 2____._.'!_.....minutes per inch Depth of Test Pit....../__ ....... Depth to ground water----/d.�___.____.- Pa' Ofir%--- - `---- -;-.'------ ---------�----------•-•-•---------•�-•--;-------•.-•------•----•-•-----...----•--••----•---•��------ , Description of Soil_-' -,------------�Q-----'�-•-------T}�'Q. � _, Qll�^?/-" - __-ca.1 _A�T��___�(A'_,.. W �p!rP9_c - 2 ••-- x q;l i4 , ------���s . �ufr U Nature of Repairs or Alterations—Answer when applicable_'_______________ _____ ____ ______ ______________________ ----------------- ��`riFr. CJ �' eo �`et.` ........._..c�_,r4 rz�4 eas/'u �c •-•-•------•••-_----- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been iss ed by the board of iealth. Signed .. ... ------------- 9 ate Application Approved BY----------�__/c__;._ 9 /e_k? •----------- ---------•--•----Date Application Disapproved for the following reasons-------------------------------------------------------------------------- ----•--------- -•-------•------•-•-•...---•-------------•---------...-v�--------•-•---••----------•-...-•---------•----------------------••-------•--------•---•--•-•--•-----[-� ............................ Permit No...X .. Issued----------------1._ T •- Dat r - Y �,• .elf THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Applirtttion for 11ispostt1 Works Tongtrnrtion unit Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal System at ..................... . ...11l�2h- ..GAT. /- ..sue. 1/,9r �' • lirs.� Loca'on- ss or Lot No. Owner Address a' ...............................' �......i ....................................t�/:t- S T"fdJ¢.-•o r Installer Address d Type of Building Size Lot. .5._Z.5.0.....S feet ` Dwelping—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder) Other—T e of Building No. of persons............................ Showers — Cafeteria 0.1 Other fixtures ............................. W Design Flow.......................11D...........gallons pe er da 10T(�tal daily flow.................. ......._.... lons. W Septic Tank—Liquid ca acit _04A allons Lent _ P q P g g -_.. h.''�/W.":_ Diameter---------------- Depth-- ---'--..._. xDisposal Trench—No. .................... Width�_..r.. ...._...... Total Length.................... Total leaching area:...................sq. ft. Seepage Pit No......._-L__-_-__ Diameter._.. X--__-_-__ Depth below inlet.................... Total leaching area ' . sq. ft.. Z Other Distribution box Dosing tank aPercolation Test Results Performed by__ ?F"T,f�Ar�,__ 1, _!- ....R..�... Date..... ' ,?'_...__.... 1.4 Test Pit No. L.L�t....._..minutes per inch Depth of Test Pit___1.2_. ...... Depth to ground water.... ----------- 44 Test Pit No. 2.......I.......minutes per inch Depth of Test Pit----1Z......... Depth to ground water---/_Yy_............... . �-�� ---- ----- _--••- ------- D Description of Soil__/.e:1.7.__•��__6......� . !'��L .e �O,$) ,�' , . ( � v 4 �`dM7At7"� ......................................................... UNature of Repairs or Alterations—Answer when applicable...._......���`':_-'` � ' "�!.................P717e1 ._ _ -*-. . Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with tfie provisions of TITLE. 5 of the State Sanitary Code—The undersigned further agrees not to place the system in. operation until a Certificate of Compliance has been is ued by the board o .health. Signed-- "' ` ---- ---------- --- �._ `1 G........ Date ApplicationApproved By.................................................................................................. ........................................ A f f Date Application Disapproved for the following reasons:................................................................................................................ ----------------------------------------------------------------------•---•-----=----•----•-•--------.._.........--...-..---------•-------•---------------------•------------------------...•-•-•-----•- Date 7 G1 - `" Permit No,.....--•................••......----•--- _ ssud i Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r�tri!.1. �/,,i,_.!r.19X!-c- -•`t-t:r ..........................................OF..........`........................................... - �rr�if txtt#� of f�ont�r�ittnr�e THIS IZT`©<CERTIFY;./That the Individual Sewage Disposal System constructed (' ) or Repaired ( ) _v_r-........ .,.--• ........ ....................................•-•--........ •--••........._._...... l /,4 1�J�r.lJ Installers ,, f����� — GL• ��/n............................................... �1 r at........--•••••....••••------•...............••-••-•••••-••••••-•--•••-•••-••••-•...-•-•-------•-•_••-- . has been installed in accordance with the provisions of TITLE- 5 of The State Sanitary Code as described in the ap�lica ion for Disposal Works Construction Permit No................... . ••••••• dated :_ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS RUE® AS UAR EE T T THE SYSTEM WILL,FUNCTION SATISFAC OR DATE'............... ...••-- -._...._.... ... .=--..` ..... . ..f. Inspector.............,..._.. ........................................... LCS�y/ fir✓ �t`` !' jr THE COMMONWEALTH OF MASSACHUSETTS 1 BOARD OF HEALTH i N OF o.f..-...��._ AE: ....... ::': 13topwial orkii �ontrl ion anti . ..e rx= Permission'is Eereby granted "eV...._ ._... to Construct ( ) or Repair ( )an Individual`SeAAra&-`Disposal System 11 at Nor.......... = -, ��' _-•----- � as shown on the application for Disposal Works Construction Permif No..................... Dated'_'__�%............................. Boar d of Health DATE.......... :. ......... FORM 1255 A. M. SULKIN. INC:, BOSTO` s � April 11 , 1985 Barnstable Board of Health Hyannis, IVIA I hereby certify that the septic system which I designed for Russell & Donna Dinius, Lots 31 & 32, Hilliard ' s Hayway, West Barnstable, IVIA has been installed and located on the ground in accordance with their Title 5 plan for said lots. The elevations ( in mean sea level) of the septic system as determined by Edward E. Kelley, Registered Land Surveyor, are listed as follows; Septic tank- inlet prop. 17. 64' actual 17. 74' Septic tank- outlet prop. 17.47 ' actual 17.45, Dist. box- inlet prop. 16. 65' actual 16.44' Dist. box- outlet prop. 16.48 ' actual 16. 25' Leach pit- inlet prop. 15. 98 ' actual 15. 73 ' l Stetson R. Hall R.S. THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I M ^C&L DATA FEE- f� i-_LAN N p F B t} RN TABLE r� � > OFFICE OF Bo` RD OF HEALT. H 1 1 Eo639e� 367 MAIN STREET MaY 4YANNIS, MASS. 02601 VARIANCE REQUEST FORM All ti r an e reque s must be submitted five (5) days prior to the scheduled Board of Health meeting. i. NAME OF APPLICANT ����� -�QNn/A �i�/�r/.� TELEPHONE N0. go-jr-(0 279 � ADDRESS OF APPLICANT 3S NAME OF OWNER OF PROPERTY LOCATION OF REQUEST .3 V, -T2 4,1*^47-1,oke I VARIANCE FROM REGULATION (List regulatilon) A 7 AIRIANZOE REQUESTED (Specific request) - ArLqr4 CC Ar r- ,E ..�. SO /4'-JC.L` F S F - i i f REASON FOR VARIANCE (May attach letter if more space needed) /0 3 t 3.2 �frJ� N -1 c),-jx 424,q ?'V? V 1 jj r %o �o�L Co-err/o•�S -�Ji-�►�G 7//4 `?�/Sr,�M COc��C'7 ro�, .�E Lo c9i .ter Ani/ d�//�,? �dC��iv.i A ✓l1�2,�wc� �E.trcc PLANS - Two copies of plan mu e subm toted clearly outlining variance requested. VARIANCE APPROVED NOT APPROVED REASON FOR DISAPPROVAL Robert L. Childs, Chairman Ann Jane Eshbaugh . H. F. Inge, M. D. BOARD OF HEALTH TOWN OF BARNSTABLE f ` , y' V"( £ e�Fy"��cv4•._ +•'� F '4."�s,,....r ri/i -1.•;�`' - "". -,�',"!,-.- ,t -�`, -, ---1 ��',.". , _ "- � �- iq " .. +' ra ryp - `1` F, , .a+ rw.F +f , A it. -a h\ «..'.}3'a,,«.+ . .!;( ,f}: r:�G�rt "+a : y S '" - 1. #'. f'a - #+A, f �\ '": .wf p .,.> a _ "r."'• a7 r t#4'.s,r ' .eV .411., iy j'L+ +}.. �' ., r .r',d,y < +�1 s!-, ! ,;..,.t s rr r . tl 5s, ■!. t r. 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