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Home My WebLink About0022 PARRISH WAY - Health f —, . - . ,`777- _ 22 PARRISH WAY, A=, 110 025.013 l i i i i e � o TOWN OF BARNSTABLE LOCATIO SEWAGE # VILLAGE/111CI.tL .¢..�� ASSESS R'S MAP & LOTOi 30S ;ISPEcQR 5- NAME&PHONE NO. A W: v SEPTIC TANK CAPACITY f O f LEACHING FACILITY: (type) C�� (size) '140400 02/Mn o NO.OF BEDROOMS BUILDER.OR OWNER " PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table acid Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) 7F et Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by p/cd 3 �. 6a i 40' L ASSESSORSMgp /l�. . PARCEL Na j2 2.,•"�4 %1.,' ' THE COMMO ALTH �ACH � TS BOA ALT� TOWN O�F BARNSI BLB Appliration for Dig, 1�ttl wtfft Tart-o -rurtion ramit Application is hereby made for a Permit to Construct ( )-'or Kc 'air ( ) an Individual Sewage Disposal System at: Location-Address T or Lot No. ....•...... 1! ---.C':!-.._ wncr Address--_-• Installer Address Type of Building Size Lot___ !.,. s _..._..Sq. feet U .. Dwelling— No. of Bedrooms-----_---------__4----------------.---.--Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons.___________________..___-_- Showers ( ) — Cafeteria ( ) a' Other fixtures _______________________________ _ _ W Design Flow..................................... r__gallons per person per day. Total daily flow.... -0..............................gallons. WSeptic Tank—Liquid capacity-V_�; gallons Length---��?_: .. Width-.��-_'�'__._ Diameter--.—.-'.-. Depth_.-��._.. x Disposal Trench--No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No............. .... Diameter-------//........ Depth below inlet..__.."........... Total leaching area.A.&.L...sq. ft. Z Other Distribution box /) Dosing tank ( ) _ ~" Percolation Test Results Performed by.._�.Ev. .4Y4.......................... A--�..-.-d&................ ,.a Test Pit No. 1Ls6S.<_.'O�ninutes per inch Depth of Test Pit_._1z. -----___. Depth to ground water....�-.......... Li, Test Pit No. 2................minutes per inch Depth of Test Pit--------............ Depth to ground water........................ Q'+ ................................. •--••-••-•-- -------..-••...........................................:........................... O Description of Soil--- 5. �"J�s - c� ............................................. 3 .... .!3L4__N 196.t.,1- ..._ d_e e71 ..� G t c✓L.a/' ..........................................•--._._....-----.......................................• W UNature of Repairs or Alterations—Answer when applicable................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee ssued by the board of health. Signed .............................. ............... --------... ..... ..------------------.. ........... .: 3:�.-� Dace Application Approved By ..............�u ..�... ................... . . .................................. ....... ... 1�... -�/'S Application Disapproved for the following reasons: ........................................... ..................................................................... ........................................................ . ...............................-- .-- .. ........................................ Dare Permit No. .. ....: �..� .,��......._ Issued ............ ....,�. .�a....- fie..:........... Dare ,+i.��'....++rr+'G-a..� "�. r,1•--..s.-.s�.usS..«......, +�,�:..J.6''�... y..._....�.�:+.J�'"s -.. .+v.::�,.--w••-...,....,.a...,.-._.w..-r..�U•�vwn�,..r•..m .�' C:. ..•�.n........._.....4r.....-^.•�M.f. Y�. No.R -r_lna. � � aJ Frnc......./ .b........ s - THE COMMONWEALTH OF MASSACHUSETTS r BOARD OF HEALTH_ TOWN OF BARNSTABLE Apphrntinn fur Di;ywml World, Towitrnrtilan �Camit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ................g ... �+ � Z-`i- .................................. '��/A�/ Location-Address or Lot No. • Y1C ✓ ....................................... -------•----•-•------•---•------------•••-------......--•-•••---••----••......------.............. ..................!r1....j y Owner/ Address ........... Installer Address Type of Building Size Lot.... �. ...._._Sq. feet ►� Dwelling— No. of Bedrooms...................---------....___-.-----Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) \ Otherfixtures ......................... ------------------------------------------------------------ .............................................................. W Design Flow................................S S-._gallons per person per day. Total daily flow.... 4 _-.----__-...................gallons. WSeptic Tank—Liquid capacity.l.�o gallons Length...�0' r.. Width_5-�--- Diameter_.- '-_. Depth.:5--_fir...... x Disposal Trench--No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No.............s?._.. Diameter.......!,........ Depth below inlet.._...4.......... Total leaching area..+44....sq. ft. Z Other Distribution box Dosing tank ( ) a Percolation Test Results Performed by.._3>.4.y.4-!K.................................................. Date./A'2_7:.��_._.___....... .. ,.a Test Pit-No. 1C sue. -minutes per inch Depth of Test Pit.....12Z-__.___ Depth to ground water..-.-. Li[ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 -•-•------•------------- -------------------------=------------------ --------------------------- ............. .._....... .._•------._.... ----------•• D Description of Soil �' '� '-v!+� w�a- sr -- -------- ....VJ/.. r' ................................•••-••-----....--••••......--•-•------•-- W 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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board ofhealth. SIg � ned - - ,...-`T -..... .............._----- .......... ........ ../�.� d rDa[e ApplicationApproved By .............. -----------...---------------------------.-. ............. -:�. Application Disapproved for the following reasons: . ...... . ................................ . .. ................................ ......................... .................................. . . ... ...................................................... .............................. Da[e Permit No. ....��..; i.......- ° { �� Issued ............3....�...3.. .....C�.. .--------• ` � Dare THE COMMONWEALTH OF MASSACHUSETTS ? BOARD OF HEALTH TOWN OF BARNSTABLE (�ertif rate of Tomplian e THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (✓ ) or Repaired ( ) by ...... ............... ..g ., .Q.. ------------------ ............................................................. ........... . ................... �: Ins[allcr at ........GtJ,q lZe-.hc1-.......��............��✓j/�/�S. ......... /11.�1.,1._._ _ ......_...._....... has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ..._. .,. dated .....�,.....__... .. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE _ ONSTRUEA AS A GUARANTEE TH" SYSTEM WILL FUNCTION SATISFACTORY. DATE ----- ....7./ .... ------------ Inspector -....._. ---------------................................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No...��...:.�r�.o?S FEE..... ....... din la tt1 nr�� Tonstrurtion Wrnfit Permission is hereby granted------------------ --------------•----------_ .................................................. to Construct (✓) or Repair ( ) an Individual Sewage Disposal S stem at No.-----• 11a �v�7 t ' r�s��!�c � --------------ll/A......`�[" r n! J6�---- t- �� K Jtrcct C� // •. as shown on the application for Disposal Works Construction Permit No.L:_�_-ld;_�__ Dated........................................... •-•------•-----------------------------•-- •---•-------..........---------------------•----•---••---•---- Board of Health DATE-------------------------------------------------------------------------------- FORM 36508 HOBBS♦k WARREN.INC..PUBLISHERS Fee-----��-- 1�- �---- BOARD OF HEALTH TOWN OF BARNSTABLE Zipp(ication-*rVell Con5tructioni3ermit Application is hereby made for a permit Qpto Construct ( ), Alter ( ), or Repair ( )an individual Well at: -�-�--�-��----�/•l2f l S�_(.�i4�/__-Y•' �-- -- le-��%U ®�1/1��—02�0>3_-------- Location — Address Assessors Map and Parcel 3-mr -fv1AG 2OY - - U2 3 L Owner Address --- - _- - --- - - - - -- - Installer Driller Address Type of Building Dwelling Other - Type of Building----------------------------------- No. of Persons--------------------------- — --- Type of Well-- n►erj7�-- -p=— Capacity---------- --------------------------- Purpose of Well------- - - - - -- - - -------- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Cer ' 'cate .of Com liance has been issued by the Board of Health. Signed —��L"`" ------------------ - ` / - date Application Approved By ------------- date Application Disapproved for the following reasons:------------------------------------------- ------------------------------------------------ q date Permit No. - -/_ ,- ----- Issued--- -- - ----- - —— ---- date BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( ) by----------- - - W_ A�------- --- --------------------------------- ------------------ L+ Installer at has been installed in accordance with the provisions of the Talwn of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. 10--- _Dated `-1--- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE---- ---—-- -- - ----- Inspector------------------------------------------ ---- s •-..•sj•�.irv`,L"� ✓ Yf "`r*�•I't�-nv.G ...' 1.4ky!t3:wPw-' tyil ri`C '�"' 'r "s`��'.`�t"RStr•S r`�r.�i. rlltt��°"ir +V` "�T'�1••.k.fls4.rrr ,y,,ISJ �"'"'�.L ,. { 5- '"'� RF�- @.r`- h1'.;tY:.•+"G_]r tY�`�s; a - ` - ,•+• ' x ,` eee•••r"' BO RD OF_,HEALTH l " Y TOWN OF BARNSTABLE Application-*rVell Cootructiot pOm" it Application is hereby made for a permit 'to Construct ( ), Alter ( ), or Repair.( )an individual Well at: ---- -04,ur3_t� L'`4 -- �3 - - Y - -- ® --- - -- --- -- - -- --- ---- Location - Address Assessors Map and Parcel 191A4 OY - - --- - --_---- d o s b,_e'has- rh �w�/� _- i,q_a?G 3 z Owner Address �P -- --- - --- - ----------- 5 - Installer.- Driller -_-_ Q'R'•='- ' Ad�ress' • Type of Building r, Dwelling ---„- G Other - Type of.Building--------------- ------------- No. of Persons-------------- ------------- ---------- Type of Well- G- - /- v Capacity------------------- --------- - --— { Purpose of Well-------------------------- - - — ---- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The.- Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well-in operation until a Cer • cate .of Compliance.has been issued by the Board of Health. �I j -- - ------ - ��-- --_—_ Signed date j Application Approved By - u — - -- - -- —--—— date Application Disapproved for the following reasons:-- -------------------------- ------------ -- ------ - ------ = - ---------------=-==---------------------------------------------- ---------------- i date i Permit No. --- - -� '=-�1" "-- -- - Issued--- -- - - --- - --- --- - date s..+o�.�m'wac+qrr�swarara�.wr,®s,�®•�.s�.-�a:�®��-�:�•-a.oraaaa'�m►rve...,+q.a..�.+. -��:emery.os.®:��.��u.�w=o�.o®r�v.��e��we�� BOARD OF HEALTH ' XPA4X TOWN �OF BARNSTABLE +/p f rtif sate ®f Compliance THIS IS TO CERTIFY, That the Ind victual?Well Constructed ( ), Altered ( ), or Repaired,( � bY- - -- - -- - -------- --- - ---------------- - --—--- -- -- 1 ; —�! - -- Installer ate - - ��`'-'- �^`-- ��-�'e!' - � •- 'sr!, �- - has been installed in accordance with the provisions of the'lo of Barnstable Board of Health Private Well Protection z Regulation as described" the application for Well Construction Permit No'for Dated'- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILD FUNCTION SATISFACTORY. DATE-------------- —-- - —-- Inspector--- - --------------------------—-- ---- a BOARD OF HEALTH TOWN OF BARNSTABLE Vell Con0ruct ion Permit No. -Ab--- �= Fee -��---- i Permission is hereby granted- i� � --- - - --- -------- --to Construct ( }; Alter ( ), or Repair ( ) an Individual Well at: - x.. ° Stree as shown on the application.for a Well Construction Permit No.=------- - t'--' --- ----------- - - Dated � - • ------—-----—______—_— -f ----------------------- ------.-. F .. .. ._._ i Board of Health DATE---- -- -= — -- ENVIROTECH LABORATORIES, INC. MA Cert. No.: M-MA 063 449 Rte. 130 • Sandwich, MA 02563 (508)888-6460 • 1-800-339-6460 FAX(508)888-6446 CLIENT: Assurance Const. Co. LOCATION: Lot 24 ADDRESS: 94 Susan Lane Parrish Way Brewster, MA W. Barnstable, MA SAMPLE DATE: 4-1-95 COLLECTED BY: L. Wile & Son DATE RECEIVED: 4-1-95 TIME: S:OOPM LAB I.D. NO. : E4-05 JOB TYPE: New Well SAMPLE I.D.NO. E4-05 WELL SPECS. : 95' 4" PVC 54' static FLOW: 20 G.P.M. RESULTS OF ANALYSIS: Parameters Units Recommended Limit Result Coliform bacteria/100ml (MF Method) 0 0 pH pH units 6.0-8.5 6.94 Conductance umhos/cm 500 98 Sodium mg/L 28.0 8.7 Nitrate-N mg/L 10.0 0.26 Iron mg/L 0.3 0.08 Manganese mg/L 0.05 0.002 Volatile Organics ug/L See enclosed report. EPA Method 601/602 None detected. COMMENTS: Yes No WATER IS SUITABLE FOR DRINKING OSES FO PARAMETERS TESTE . XXX S d Date ; Rona d J. S ri Laboratory 'rector LT = Less Than GROUNDWATER ANALYTICAL EPA METHODS 601 and 602 Volatile Organics (GC/PID/ELCD) Field ID: E405 Lab ID: 10341-01 Batch ID: VG2-0688-W Project: Assurance Cons Co/Lot 24 Parrish Way Sampled: 04-01-95 Client: Envirotech Received: 04-03-95 Cont/Prsv: 40mL VOA Vial/HC1 Cool Analyzed: 04-05-95 Matrix: Aqueous PARAMETER CONCENTRATION REPORTING LIMIT (ug/L) BRL 5 Dichlorodifluoromethane BRL 5 Chloromethane BRL 5 Vinyl Chloride BRL 5 Bromomethane BRL 5 Chloroethane BRL I Trichlorofluoromethane BRL I 1,1-Dichloroethene BRL 1 Methylene Chloride BRL 1 trans-1,2-Dichloroethene BRL 1 1,1-Dichloroethane BRL I cis-1,2-Dichloroethene BRL I Chloroform BRL 1 1,1,1-Trichloroethane BRL 1 Carbon Tetrachloride BRL I Benzene BRL I 1,?-Dichloroethane BRL 1 Trichloroethene BRL 1 1,2-Dichloropropane BRL 1 Bromodichloromethane BRL 5 2-Chloroethyl Vinyl Ether BRL I cis-1,3-Dichloropropene BRL I Toluene 1 trans-1 ,3-Dichloropropene BRLBRL 1 1,1,2-Trichloroethane BRL Tetrachloroethene BRL 1 D.ibromochloromethane BRL 1 Chlorobenzene BRL 1 Ethylbenzene 1 meta-and pars-Xylene * BRL I ortho-Xylene * BRLBRL 1 Bromoform BRL 1 1,1,2,2-Tetrachloroethane BRL 1 1,3-Dichlorobenzene BRL I 1,4-Dichlorobenzene BRL 1 1,2-Dichlorobenzene QC SURROGATE COMPOUND SPIKED MEASURED RECOVERY QC LIMITS a,a,a-Trifluorotoluene 30 30 100 % 87 - 113 1,2-Dichloroethane-d4 30 32 108 % 83 - 117 BRL = Below Reporting Limit. * Non-target compound. Method References: Method 601 - Purgeable Halocarbons and Method 602 - Purgeable Aromatics, 40 C.F.R. 136, Appendix A (1986). I pMYl.ljN' c710 r a:u oG 41. �avJTM701j ►a W�-Vm o'v ----�va-d $o-Ur E _1lzrMru - '00 V- vLrClY D(rJ I i 'rr��y�.o�v� 1n''� �v��t, �vv✓.�� 1 dni,i ��0 Unto q uo Omar vn i,C ?-ar !n4_11J✓ ff\� pvo\, I'OT kvPl bh �,. 2N 14 14 oo0�-2':;11�+�_ v mos YFIVIwd 7)cP 18s h ch�J ?am p"o °'';l Dti 99t7 r; amrava; Ut,t, 014 -mock 0 �'C8 ? p v;;r001417 v9 PJ Io F c.I,r COB i I � V9soJoY,.1 S4 0,0Z PSM I v i� 1 •hoof �� I ti 1 4_` w Rio oas REC IV6 BORTOLOTTI CONSTRUCTION,•INC. 765-WAKEBY ROAD,MARSTONS MILLS,MA 02648 S EP -771-9399 508-428-8926 FAX: 508428-9399 TO HFBARNSTAB LTHDfpr.. USUBSU ACE SEWAGE DISPOSAL_SYSTEM INSPECTION FORM 4 PART A 49 9 CERTIFICATION G Property ress: rV Date of Inspection: 97 Inspector's NAV Q.qtqier's Name and ddress: CERTIFICATION STATEMENT: I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of inspection. The inspection was per- formed based on my training and experience in the proper function and maintenance of on-site sewage disposal rtems. The System: Passes Conditionally Passes Needs Further Ev ation By ocal Aproving Authority Fails Inspector's Signature: 114-4 Date: 9' The System Inspector shall submit a copy.of this.inspection report to the,Approving authority within thir- ty(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, INSPECTIOON SUMMARY: A)SYST PASSES: ✓ I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system,upon comple- tion of the replacement or repair,passes inspection. Indicate yes,nor,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,cracked, structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing sep- -tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup or breakout or high static water level observed in the distribution box is due to broken of obstructed pipe(sj or due to a broken', settled or uneven distribution box. The system will pass inspection if(with approval of The Board of Health): -1 SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART A t CERTIFICATION(continued) ' Broken pipe(s)replaced T y . Q Obstruction is removed .' Distribution Box is levelled or replaced The System required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of The Board of Health): ` t Broken pipe(s)are replaced Obstruction is removed C)FURTHER EVLUATION IS REQUIREDrBY THE BOARD OF HEALTH Conditionse t xist 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 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 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 APPROPRIATE)DETE RMINES THAT THE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND.SAFETY AND THE. ENVIRONMENT: The system has a septic.,tank.and soil absorption system and is within 100 Feet to a surface ":water supply or tributary to la surface water supply:. The system has a septic tank and,soil absorption system and,is with a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. The system has a septic tank and soil absorption system and 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 the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D)SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined 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. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent 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 clog- ged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or,available volume,is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A . CERTIFICATION (continued) 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 I 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: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 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: 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. The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: Pumping information was requested of the owner,occupant, and Board of Health. �GNone of the system components have been pumped for atleast two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been / introduced into the system recently or as part of this inspection. As-built plans have been obtained and examined. Note if they are not available with N/A. __6Zfhe facility or dwelling was inspected for signs of sewage back-up. _ZThe system does not receive non-sanitary or industrial waste flow. _1,f-�The site was inspected for signs of breakout. All system components,excluding the Soil Absorption System, have been located on site. J�The septic tank manholes were uncovered,opened,and the interior of the septic tank was in- spected 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 or approximated by non-intrusive methods. -3- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B' CHECKLIST(continued) /Thenif different from owner were rovided with information on facility owner(and occupants, ) p the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION - b FLOW'CONDITIONS RESIDENTIAL__ Design Flow: gallons Number of Bedrooms: 7 Nu r of Current Residents- Garbage Grinder: Laundry Connected To System:W2= Seasonal Use: Water Meter Readings, if ailable: Last Date of Occupancy: - 67 COMMERCLALANDUSTRIAt J() Type of Establishment: Desi gn Flow: a11onsldaY 'G rease Trap Present: Yes or no) Industrial Waste.Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information System Pumped as part of inspection: ljo If yes,volume pumped: gallons Reason for pumping: TYPE F SYSTEM: - eptic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records, if any) Other(explain): PROXIMATE AGE of all components,dqte installed(if known)and source of information: Q Sew ge odors detected when arriving at the site: _ - -4 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: Depth below grade: Q' Material of Construction: concrete metal FRP_Other (explain) Dimisions:/D.,S',1 j Sludge Depth: / '' Scum Thickness: Distance from top of sludge to bottom of outlet tee or baffle: 37 Distance from bottom of scum to bottom of outlet tee or baffle: 9" Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid lev l in r at on to tlet invert,structural integrity _vidence of leaks e,etc.) i rr GREASE TRAP:�� Depth Below Grade: Material of Construction—concrete_metal_FRP_Other (explain) Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle: Comments: (recommendation for pumping,condition'of inlet and outlet tees or baffles,depthof liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.) TIGHT OR HOLDING TANK: Depth Below Grade: Material of Construction:_concrete_metal_FRP_Other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm Level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: o� Depth of liquid level above outlet invert: Comments: (note if 1 vI and distribution i§_e ual,evide a of solids carryover,evidence o leakage into or out of box_ 644" Q PUMP CHAMBER: Pump is in working order: Comments: (note condition of pump-chamber,condition of pumps and appurtenances,etc.) -5- " s SUBSURFACE SEWAGE,DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM(SAS): !/ (Locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: Leaching pits,number: Leaching chambers, number: Leaching galleries,number: Leaching trenches, number, length:. - Leaching fields, number,dimensions: Overflow cesspool,number: Comments: (note condition of soil,signs of hydraulic failure 1 el of po ing,condition of ve etation, et ) 07- U t�V_ ii Al ii CESSPOOLS:/-)0 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 must be pumped as part of inspection) Comments: (note condition of soilk, signs of hydraulic failure,level of ponding,condition of vegetation, etc.) PRIVY: /V t/ Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) -6 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: 1 Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. n qq 4u �a DEPTH TO GROUNDWATER: Depth to groundwater: ,3Z Feet Methad of Determination or Ap,proximation: .�QdS -7-