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HomeMy WebLinkAbout0024 PARRISH WAY - Health 24 PARRISH WAY, A= 110 046 _ ° Iw-oy6 Commonwealth of Massachusetts Title 5 Official Inspection Form �= I'. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Parrish Way Property Address JC Murphy Owner Owner's Name information is West Barnstable Ma 02668 12-9-19 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling ou:forms A. Inspector Information on the computer, Brett Hickey use only the tab key to move your Name of Inspector , cursor-do not B&B Excavation use the return Company Name key. Q 374 Route 130 OCompany Address Sandwich Ma 02563 City/Town State Zip Code rrx (508)477-0653 S113747 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. 0 Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails o��.y,q�wa�M�„ Brett Hickey ��m= � �,o•a,•�,� �ro�� .�•F�s 12-9-19 moo:W19.121113—.osm Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flaw 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Parrish Way Property Address JC Murphy Owner Owner's Name information is West Barnstable Ma 02668 12-9-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3,or 5 and all of 4 and 6. 1) System Passes: ❑■ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: The system was in working order at the time of inspection. 2) 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. Check the box for"yes", "no"or"not determined" (Y, N, ND)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. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Parrish Way Property Address JC Murphy Owner Owner's Name information is West Barnstable Ma 02668 .12-9-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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 ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ 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 ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑' Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. 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: t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 i c Commonwealth of Massachusetts i� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Parrish Way V� Property Address JC Murphy Owner Owner's Name information is West Barnstable Ma 02668 12-9-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water j ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh I b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent 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. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ a Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ El Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form + Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Parrish Way V� Property Address JC Murphy Owner Owner's Name information is West Barnstable Ma 02668 12-9-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ 0 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool � El Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ❑ 0 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ El Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ El Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ 0 Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ [El Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ El 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 fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.] ❑ El The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ 0 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. 5) 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 CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 i c Commonwealth of Massachusetts �a Title 5 Official Inspection Form l� Subsurface Sewage Disposal System Form Not for Voluntary Assessments � 24 Parrish Wa Y u— Property Address JC Murphy Owner Owner's Name information is West Barnstable Ma 02668 12-9-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant n question in Section CA above the large s threat, or answered "yes"to any que stem has failed. The g y owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. . 6. You must indicate yes or no for each of the following for all inspections: Yes No Q ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ El Were any of the system components pumped out in the previous two weeks? ❑ M Has the system received normal flows in the previous two week period? El El 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 ❑ NA available note as N/A) ❑ El Was the facility or dwelling inspected for signs of sewage back up? x W he site inspected for signs of break out? ❑ as t ❑ P 9 0 ❑ Were all system components, excluding the SAS, located on site? El ❑ 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? ❑ 0 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(5)] t5insp.doc-rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts �v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Parrish Way V Property Address JC Murphy Owner Owner's Name information is West Barnstable Ma 02668 12-9-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: No design plans 4 Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): NA Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes El No Does residence have a water treatment unit? ❑ Yes 0 No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ❑ No information in this report.) Laundry system inspected? ❑ Yes RI No Seasonal use? ❑ Yes [E No Water meter readings, if available(last 2 years usage(gpd)): See below Detail: WELL WATER Sump pump? ❑ Yes ❑■ No Last date of occupancy: End SeptemberDate t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 I c Commonwealth of Massachusetts �n Title 5 Official Inspection Form Io Subsurface Sewage Disposal System Form Not for Voluntary Assessments t 24 Parrish Way v Property Address JC Murphy Owner Owner's Name information is West Barnstable Ma 02668 12-9-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: NA 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: 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 below): ` 3. Pumping Records: Source of information: Owner- pumped 3 years ago Was system pumped as part of the inspection? ❑ Yes ❑■ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 i Commonwealth of Massachusetts �h Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Parrish Way v Property Address JC Murphy Owner Owner's Name information is West Barnstable Ma 02668 12-9-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ' El 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)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: unknown due to lack of record Were sewage odors detected when arriving at the site? ❑ Yes 0 No 5. Building Sewer(locate on site plan): 216r' Depth below grade: feet Material of construction: ❑ cast iron Q 40 PVC ❑other(explain): Distance from private water supply well or suction line: >100'feet Comments(on condition of joints, venting, evidence of leakage, etc.): l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I'1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Parrish Way v� Property Address JC Murphy Owner Owner's Name information is West Barnstable Ma 02668 12-9-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 1'6" Depth below grade: 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 certificate) ❑ Yes ❑ No 1 Dimensions: 500gallons 1211 Sludge depth: 2411 Distance from top of sludge to bottom of outlet tee or baffle 6" Scum thickness 4" Distance from top of scum to top of outlet tee or baffle 1211 Distance from bottom of scum to bottom of outlet tee or baffle measured How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was in working order at the time of inspection. The tank is in need of pumping at this time and should be pumped every two years for maintenance. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts rM Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Parrish Way �u Property Address JC Murphy Owner Owner's Name information is West Barnstable Ma 02668 12-9-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): NA Depth below grade: 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.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): NA Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 ,4N, Commonwealth of Massachusetts Title 5 Official Inspection Form. IQ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Parrish Way Property Address JC Murphy Owner Owner's Name information is West Barnstable Ma 02668 12-9-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): 0" Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The d-box was in working order at the time of inspection. t5insp.doc-rev.7/26/2018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 < Commonwealth of Massachusetts �n Title 5 Official Inspection Form 11 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Parrish Way L Property Address JC Murphy Owner Owner's Name information is West Barnstable Ma 02668 12-9-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): NA * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: (2) 6'x6' pit El leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 cam. Commonwealth of Massachusetts Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 24 Parrish Way Property Address JC.Murphy Owner Owner's Name information is West Barnstable Ma 02668 12-9-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The SAS was in working order at the time of inspection. Both leach pits had 1' of standing water when viewed. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site pla n): NA 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.): l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts �m p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Parrish Way v� Property Address JC Murphy Owner Owner's Name information is West Barnstable Ma 02668 12-9-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 c Commonwealth of Massachusetts �d Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Parrish Way Property Address JC Murphy Owner Owner's Name information is West Barnstable Ma 02668 12-9-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ❑■ hand-sketch in the area below ❑ drawing attached separately Shed B A Al-27 1 A2.28" A3.38`6" 61.24` - B2.2T 63.35' Pool 3 0 0 t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts �d Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ...........< /� 24 Parrish Way V Property Address JC Murphy Owner Owner's Name information is West Barnstable Ma 02668 12-9-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ■❑ Check Slope ❑■ Surface water Check cellar ■❑ Shallow wells Estimated depth to high ground water: No GW @ 20'feet 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: Date El Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators installers- attach( documentation) El Accessed USGS database-explain: see below You must describe how you established the high ground water elevation: Topo maps and charts were used to determine high groundwater. Ground water is >20' showing bottom of SAS is >5' above high ground water. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Parrish Way �u Property Address JC Murphy Owner Owner's Name information is West Barnstable Ma 02668 12-9-19 required for every page. City/Town r State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: A. Inspector Information: Complete all fields in this section. �■ B. Certification: Signed& Dated and 1, 2, 3, or 4 checked ❑� C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6(Checklist)completed ❑■ D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included P P 9 t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 N- 9 9 NEBShc.cmMUkmm.ibOrderPMaIFMLLfREEI-M-225-SM PRODUCT 258 BORTOLOTTI CONSTRUCTION, INC. 765 Wakeby Road 10 �`4`1 a �' MARSTONS MILLS, MA 02648 RSCE 508 7719399 R (5O8) 4ZH'H926 DATE OF ORDER M ,�� 19g6 _ 76 t CUSTOMER'S ORDER NO. PHONE MECHANIC HELPER STARTING bAT�E 6 E' BILL TO DER TAKEN B V v 7/0 �. ADD SS /- /�� / /�h ❑ D WORK ONTRACT ❑ EXTRA Y ^ I r JOB NAME AND LOCATION JOB PHONE U- DESCRIPTION OF WORK CTOTAL MATERIALS TOTAL LABOR V"v TAX DATE COMPLETED WORK ORDERED BY 71- 6 TOTAL AMOU T $ Q l ❑No one home ❑ Total amount due for above work:or be mailed after Signature completion I hereby acknowledge the satisfactory completion of work •• of the above described work. __ 7, BORTOLOTTI CONSTRUCTION,LNC. 765 WAKEBY ROAD, MARS'TONS MILLS, MA 02648 508-771-9399 508-428-8926 FAX: 508-428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: n s/ Cc C/ Date of Inspection: - Inspector's Name: Owner's Name and Address. �10122 VL c </n`S�.�f 142- 51/ CERTIFICATION STATEMENT: I certify that I have personally inspected the sewage disposal system at this address and that the infornia- 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 sys s. The System: Passes Conditionally Passes Needs Furth, Evaluation By the Local Aproving Authority Failrure /> Inspector's Signa _ Date: The System Inspector shall submit a copy of this inspection report to the Approving authority within thir- (y(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. ENSPECTION SUMMARY- A)SYSTEM•PASSES: 1 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 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): - 1 - L SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Broken pipe(s)replaced Obstruction is removed Distribution Box is levelled or replaced The System required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if withapproval of The Board of Health): Broken pipe(s)are replaced Obstruction is removed 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 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 IIEALT II•(AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT T RE 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 a 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 sY stem 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 ppni. 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 e[luegt 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 N I 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 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: The following criteria apply to a large syste►n in addition to Lhe criteria above: The design,flow of a system is 10,000 gpd or greater(Large System)and the system is a sig►uficant 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 (1WPA)or a mapped Zone 11 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. ✓None 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. r" As-built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. v"The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. e'All system components,excluding the Soil Absorption System, have been located on site. 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. k"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- r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART l3 CHECKLIST(continued) _zThe facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION / FLOW CONDITIONS Design Flow: gallons Number of Bedrooms: �� Number of Current Residents: Garbage Grinder: ye—s Laundry Connectcd To Systcm: � Seasonal Use: Water Meter Readings, if a ble: Last Date of Occupancy: COMMERCLWINDUSTRIAL•/1 Type of Establishment: Design Flow: gallons/day Grease 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 /f „ PUMPING RECORDS andsource of infoniiatJ`on: /� 'CVe P �?(�m6/���, System Pumped as part of inspection: 1Z� If yes,volume pumped: gallons Reason for pumping: TYP F SYSTEM: Septic Tank/Distribution Box/Soil Absorption Systcm Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records, if any) Other(explain): AP ROXIMATE AGE of all components,date installed(if known)and source of information: s - o/_, - S 'fv-e"� Sewage odors detected when arriving at the site: d -4- I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART•C GENERAL INFORMATION (continued) SEPTIC TANK: 1/ Depth below grade: _'Jo Material of Construction: ;,-,,concrete metal FRP Other (explain) Dimisions:/O,5'X Sludge Depth: :S" Scum Thickness: e " Distance from top of sludge to bottom of outlet•tee or baffle: Distance from bottom of scum to bottom of outlet tee or battle: 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.)_�,�'S C /S c�a " cJ (� oL b4 i77 r'7 D< l' LCf e /79,4/%7 p,9aloe'e Lt 17,1/o 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, depth of 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: y Depth of liquid level above outlet invert: ZJ6� Comments: (note if level and distribution is a ual, evi ence of solids carryover,evidence of leakage into or out of box, etc.j);,r ir,A„, V;&"-) ,r oL 4 2222 P i r)A,O-Pc lei`ci PUMP CHAMBER: Pump is in working order: Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) -5- SUBSURFACE SEWAGE DISPOSAL SYS'.I'EM INSPECTION FORM PAR1'C SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM(SAS): (Locate on site plan, if possible;excavation not required, bW nuiy 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 level of ponding, condition of vegetati n, etc)_ _ 10 �lis' CESSPOOLS: — --� 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: Materials of construction: Dimensions:' Depth of Solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) ---- -- - - --- ---------- - -G - z � , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. -- by' j µ2 DEPTH TO GROUNDWATER: Depth to groundwater: o Feet Method of Determination or Approximation: >� 1./S. ' Q/' -th elr�hr I,Lec)k-/,cal CjGcr��Pr{ - 7- ' s 1 BORTOLO7T1 CONSTRUCTION, INC. 765 WAKEBY ROAD,MARS.1'ONS MILLS,MA 02648 6 508-771-9399 508-428-8926 FAX: 508-428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: Date of Inspection:_/-o70-9& Inspector's Name: Owner's Name and Address' 2Z2 /27/9 CSC CERTIFICATION STATEMENT: I certify that I have personally inspected the sewage disposal system at this address and that the infonna- lion 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 ou-site sewage disposal systems. The System: -asses Conditionally Passes Needs Further Ev uation By re Local Aproving Authority Fails InspecWr's Signature: d Date: 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. INSPECTIONSUMMARY: A)SYSTEM PASSES: I have not found any information which indicates that Ilse sysicm violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B)SYST�I CONDITIONALLY PASSES; U 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 xfrltration, 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 Icvel observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken CP�IIpd�_�nP..Pn,tOrihnlion hat The system will pass inspection if(with approval of The Board of Health): - 1- CI SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Broken pipe(s)replaced Obstruction is removed Distribution Box is levelled or replaced The System required pumping more than four times, 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.. C)FURTHER EVALUATION IS REQUIRED BY THE HOARD OF HEALTH: Conditions exist which require further evaluation by'file Board.of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1)SYSTEM WIL L 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 welland or a salt marsh. 2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECT 171E PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: " rption system, is within l0U Feet to a surface The system has a septic tank and soil abso water supply or tributary to a 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 a uilrogcn and nitrate nitrogen is equal to or less the facility and the presence of anunoni 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 G"below invert or available volume is less than 1/2 day [low. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped -2- r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM I'A RT 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 (1WPA)or a mapped Zone It 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 infornation. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been.done: y_Pumping information was requested of the owner, occupant,and Board of Health. None of the system components have been pumped Im 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. -__.,,i The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. iZThe site was inspected for signs of breakout. VAll system components,excluding the Soil Absorption System, have been located on site. _ The septic tank manholes were uncovered,opened,and(lie 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. G 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 - _ :1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART 11 CHECKLIST(continucd) The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIAIa �Design Flow: `dyeZ gallons Number of Bedrooms. � Number of Current Residents:_ Garbage Grinder: �_' Laundry Connected To Sysl.cm: � Seasonal Use: lvr Water Meter Readings, if�vailable: Last Date of Occupancy(,/� COMMERCIAL/INDUSTRIAL:111 Type of Establishment: Design Flow: gallons/day Grease'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 J PUMPING RECORDS and source of information..�/ Uci �h"C�c�i�iii-Ci System Pumped as part of inspection: If yes, volume pumped: gallons Reason for pumping: TYPE F SYSTEM: Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records, if any) Other(explain): AP ROXEVIATE AGE of 11 components,date installed(if known)and source of information: Sewage odors de ected when arriving the site: ,L -4- I .SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: Depth below grade:_,)p Material of Construction:�'___`concrete metal FRP_Other (explain) Dimisions: '5`X X 7' Sludge Depth: Scum Thickness: !a- Distance from top of sludge to bottom of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or ba.flle: 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.) S /L- s iL Alt 6J t-� " VA r-e c. Ace 1?n t' f ', � ' , " S —// s c� �� c -ce oz j,,9/�t�rbi°o.7 . i/ � 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, depth of 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 alarnn.and float.switches,.etc) .r DISTRIBUTION BOX: Depth of liquid level above outlet invert: L�/6 0'p4- Comments: (note if level and distribution i qual, evidence of solids Zover,evid nce of leakage into or out of box,etc.) ' r LZE�r o PUMP CHAMBER:. � Pump is in working order: Comments: (note condition of pump chamber, condition of pumps and appurtenances,etc.) 5- 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: 02- 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 level of ponding, condition of vegetation, etc.) I11"— cwe oZ - l S. N Y9L Cl%�' 1f! !1 ,fcsti� CESSPOOLS: A10 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: Material40construction: Dimensions: Depth of Solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) I -6 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to Weasl two permanent references, landmarks or benchmarks. Locate all wells within tOO Feet. Oo r � f o '6 �►et DEPTH TO GROUNDWATER: , 'I Depth to groundwater. 34 Feet ;`y Metho f Determination or Approximation: ;��XI ll/ ll �i '/�J �� ,�, 12 ( " -7- TOWN OF BARNSTABLE LOCATION a`�, !^/�i �1 L(JG.�� SEWAGE # VILLAGE �N('J� /�illS�r��ti% ASSESSOR'S MAP&LOT DMEU;hE�ailS�G��7 // ' NAME&PHONE NO. r 4d/6 , SEPTIC TANK CAPACITY k0Q QG//Vl2�VIL— 01 Z' 10( C LEACHING FACILITY: (type) �� [� �/ (size) NO.OF;BEDRO BUILDER R OWNE �� PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist P} XZ on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching fa "�'') /�! Feet FurnishedbyCA6r,/Z)/ a, l sk 0 U � r� 1 TOWN OF BARNSTABLE LO: ATION ��i l'r-f*ts SEWAGE # VILLAGE ��p, S� 9e-�S ASSESSOR'S MAP & INSTALLER'S NAME & PHONE NO. (dofo� / CDiL• �� � SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) .Cx jp NO. OF BEDROOMS RIVATE WELL R PUBLIC WATER BUILDER R OWNER ;��n� Ad Car�1/ � DATE PERMIT ISSUED: - aC) -�cj DATE COMPLIANCE ISSUED: - Js VARIANCE GRANTED: Yes No r 2 - 1,2 / 6 y -s 7 � + 1 THE COMMONWEALTH OF MASSACHUSETT$ �Ib ( BOAR® OF HEALTH ------.....-OF..........J Appliration for Dispoii al, Works Tnntrnrtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at � a s �- Cva- :... -��sQ�1�---------------- ---- ................._.. •-------------=---- • d ess-------- » Locatio Ad Tess or Lot No. Address ]� ....law .................. WO Installer Address d Type of Buil Size Lot . ......... ----Sq. feet DwellinAko. of Bedrooms-------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) r,., Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a Other fi tures ....._._ __ ._ d ----------------------------------------------------- ---------- W Design F}�ov 1rri . mob/_ allons per person r y. Total Ala ly flow._____...I.. d.......................... all�_ Width. Diameter________________ De th....... .._.. WSeptic T, iwd'capacit ............gallons Length �. . . . p x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area............ . ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Tota1�a, In t Z Other Distribution box ( ) Dosing ( ) L T. Percolation Test Results Performed by Dosing - -�-•--•-•Faf .•---�-•---------- Date `�1��/..r-�- aTest Pit No. 1................minutes per inch Depth/of Depth/of Test Pit.................... Depth to ground water........................ Gi, Test Pit No. 2______________minutes per inch Depth of Test Pit.................... Depth to ground water........................ 04 t�lterations --•• -- ----------•---•-•-?hen --------------------------------•------. ........._....--------•----••-------------------•-.........._...._O Description of Soil -- ----------------------•-••- •----------- ----- --- r-------------------------- ------ •-- ---- -... ................ ---­------------- ------ UNature of Repa' s or --Answer pplicable...._-.__-.-•_____________________________________________________________ _______ _____ -•---------------------------------------------••••--------•---------------•----------------------••--------•-----•---------------------•----------------•-----••----------------•----------.._......... Agreement: The undersigned agrees to install the aforedescribed ndividtial Sewage Disposal System in accordance with the provisions of iITL 5 of the State Sanitary Code— e undersigned further agrees not to place the system in operation until a Certificate of Compliance has b ins the4board healthh.�. 17 Signed--- ....•----• •--- .....�Z :.?4 - -...A..9..._ Date Application Approved By--------- ---------------------------------------- Date Application Disapproved for the following reasons-----------------------------•-----------...................................................................... s p Date Permit No.......3-�A-"»�f..`..�... Issued_....................................................... Date e No.4.2:..5 Z... FEs.......7:.�...:. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................O F..........................---...............-........... Appliraation for Disposal Works Tnnstrurtion umit Application is hereby made for a Permit to Construct ( ) or Repair ( _) an Individual Sewage Disposal System at: i �f / -,? . h !s W Q f ( /:G Y a.... ...........................r. t-No.......................................... '•� Locati�` Ad Tess - -•••-•----------------••.----.•.•-•--_....or-Lot No. .... `� . . a ��f t ...... r Address Installer Address o Type of BuiPko. , Size Lot.- .. .........I/......Sq. feet aDwellin of Bedrooms......`--/---------------------------------Expansion Attic ( ) Garbage Grinder ( ) Q1 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) 01 1 Other fixtures - --------------------••------•----------------------------------•----------------_...... d Design F�l�o.v•v� ._ . d gallons per person r #y. Total dail flow____ _--�" o l W � �>�' Septic 'lik— iqui capacat _.....____._gallons Lengths ..... Width.. .�-_. Diameter________________ Depth................ WDisposal Trench—No. .................... Width.................... Total Length.................... Total leaching area...............-----s . ft. , x Seepage Pit No.-_--------------- Diameter.................... Depth below inlet.................... TotaeTinp., ftZ Other Distribution box ( ) Dosmj'Percolation Test Results Performed by.._! _�, S:Q_......._�_.1..UG................. Date.......... /-_n-7 .y.. o,4 Test Pit No. I......... minutes per inch Depth Test Pit.................... Depth to ground water........................ i, Test Pit No. 2... ..........minutes per inch Depth of Test Pit...._.......____.... Depth to ground Ovate ........................ • -•-•----- ------------------------•--- -----------... Description of Soil,. ..._.. --• `•-. • ' ............... .. ...... U - - -• ----- •---- W `- -------------------- ---- •-- ��••- . ........ -.. . . U Nature of Repails 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 Sanitary Code—Xhe undersigned further agrees not to place the system in operation until a Certificate of Compliance has b, - is,- b the board ]f health. Signed--'- ---- . "' G v✓ccr t Date Application Approved By-------- ----K2).,.. . ................................. Date Application Disapproved for the following reasons:---------.•----------------••------...-----------------------------------------•---------------------........... ............................•----......•-----•---------------...-•---•--•--------•-•-•-•••...----------•-••. T Date...--- Permit No........ .� ------------------------ Issued Issued.--•---...-----------------•- ...---•----.._ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TrrtifirFatr of ToutpliFanrr THIS IS TO CERTIFY, That t e Individual Sewage Disposal System constructed (k) or Repaired ( ) by................ . 1�.--• -•----• ---------- ------------------------------------------------------------------------------------------------------ Installer at.......... .� .�.. - .... i�' _...-Y�/ - ----------•!.(�-------- .�, 't has been installed in accordance with the provisions of TI: .� 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.-___-4:-____.�._- _.____ dated-............................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector------------•--------- is THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .,NI :J:�?... .. OF..............j..... -?:✓c.''1: _� r/......._............... 't ........... _.-. No.- - - .. FEE.... ..... '_-_.. Disposal Works Tnnotr ion rrntit Permission is hereby granted...........a' `.�"=_.._..-/ -.'+,hr` v--------- _-- -•------------- to Construct ( ' or Repair ( ) an Individual Sewage Disposal System _ at No. �.. _ .... �' ` -vYc...SL-. --- It,i, E_- ................ Street as shown on the application for Disposal Works Construction Permit No.... :r ___ Dated.......................................... ------------------------•----------------------------------------------•-------•------...--•••----_...._ Board of Health DATE.......................................................................---...... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS Department of Environmental Management/Division of,Water Resources r WATER WELL COMPLETION REPORT / WELL LOCATION Address L-0 r�3 (r 2/.�Ce r• I/V•�d r y I, f7r E City/Town A .�� . ��% -- G.S.Quadrangle Map Grid Location Owner \j2 i 4�c (.-�) "A '..� Address �U 'U� 1. I c , JA�r�t �1 ,C WELL USE CONSOLIDATED WELL Domestic Q Public ❑ Industrial ❑ Type of Water-bearing Rock Other Water-bearing Zones Method Drilled t 1) From To y 2) From To Date Drilled 31 From To I' 41 From To CASING I l Depth to Bedrock Length y Diameter Type U S} �. UNCONSOLIDATED WELL STATIC WATER LEVEL, f Water-bearing'Materials Feet below land surface Sand: fine❑ medium 0 coarse Q Date measured c� ' lea Gravel: fine❑ medium❑ . coarse❑ Screen: GRAVEL PACK WELL , ❑/ Slot# )Z length from—to- Yes U No Split Screen (or 2nd screen) WATER QUALITY TESTS MADE Slot length from to Cfiemical [f Biological ❑ Depth To Bedrock `� PUMP TEST ^� Drawdown I�/ feet after pumping days L/hours at I OGPM. Si" ../�y How measured �1Cl- I✓p rnlrl Recovery feet after hours. LOG of FORMATIONS COMMENTS: (On well or water), Materials From To Shy• �un� �.� 'o DRILLER �. 1l1/ Firm } ,1t-,e' o,n \, l�l ) "� a Address tit ©V y� . City 1_`Ot- et k—Qk-_. .t.-t " 11w- W t / I, Registration No. �� Operator's Signature 'r . ease_ rp rnt rrm y --._......._._30A�RD OF HEALTH COPY zsM-Io-as•aonot 16p 4' x tir;:tsssst:s::r sss s:s;;stss:srs:t ttssstsnsr.:tstsr F: :r:t:s::::nsrts:s sr t F Fsstss:s3rF;; ;;;sts rx:sr3:rr s s ssnss:Fs s s s ssss ssns::sFrsss s ssrs::rss:sr n t e;Fs::;rsr;n;;ss Fsts sss:t:s:ss:s;f .,,,,,,,;,,,,, ,f:,ff:,::,::,::,,::i,f::,:,:::::::::, :,f.,ii ,i,:,,,::,::::,,i„i„ii i. .:,,,,,,,...ii... „xf:,:::::,:i,if fff if:::,:::.:f:F ff,ii:i,,,,ff,,:t:::f:.,:,:ii,i,,,,,,:,,,,,tf:,t,#i,,,,;;: #::i,,:,t,;:,:::, :F ENVIROTECH LABORATORIES _ 449 Rte. 130• Sandwich,MA 02563• (617) 888-6460 - CLIENT: Peter Hawley RE LOCATION: Lot 23 Cedar St. ADDRESS: Box 317 W. Barnstable E. Sandwich,MA 02537 COLLECTED BY: Meehan SAMPLE DATE: 2/16/88 TIME: 3:30 PM _ DATE RECEIVED: 2 17 88 SAMPLE ID: E 588 JOB #: New Well WELL DEPTH: 120 ft RESULTS OF ANALYSIS: Parameter Units Recommended limit Result - Coliform bacteria/100 ml (MF Method) 0 0 pH pH units 6.0-8.5 7.10 Conductance umhos/cm 500 76 Sodium mg/L 20.0 8.1 Nitrate-N mg/L 10.0 .08 Iron mg/L 0.3 <.05 Manganese mg/L 0.05 ;s Hardness mg/L as CaCO 3 500 Sulfate mg/L 250 x Potassium mg/L 20.0 Alkalinity mg/L 200 = Chloride mg/L 250 is COMMENT: YES NO XU ❑ WATER IS SUITABLE FOR DRINKING PURPOSES FOR PARAMETERS TE ED DATE o !' \ t.........:::t:1:::::::::::::::::::"isli:::i::::::::::::::: ::t:::::::::::::::::::: ::::::::::::::::::::::::t::::::::t...,.:.i. '::::::::::::::::°:1:':: ::::::. .. r.::ss:stss:tsustsss:ss:tss:s:ssssiiustsuss:ssu:s:»ssssltlssssssss::ssss:usssssusss»uuss»ssssu»:susssussus:ss:suss:::::::»::s:sssssssusssssusss:s»:u:ssulsssfsus:::::»f::ussisssss:::ss::::U= tiisuu::i;.W.ss�' SOIL LOG N0. 1 0 N0. 1 SITE PLAN Notes : 1. If soil data is inconsiatant 2b 1 with soil log as shown, contact Engineer `' � 5°f LS 1 and/or Barnstable B;oerd of Health. 3 2. Well and Septic locations in - , accordance with Master Plan, 2 4 f' i3. Soil Testa performed by Doyle � f TOP OF FOUNDATION El.: Engineering Asaootates• E • •• �fvTr .0q a ly •�: i� ram`,� � p✓� C ` ��` t �� 9 • �.o l- 40, ------- 10 l r IN.It ? IN.EI yi � 11 2 COVER 1/B�r •: J , . ; . - 3/e,r WASHED STONE 11 ••• Ir.�rl. . IN.ft•:� l 0/1 W/ Slump s ; ; ; ; 3/4 13 1-1/2WASHED STONE - 4 LIQUID LEVEL • , .� • , r 14 • js, � ; ; ; r�• i" EFF. DEPTH • : ' 1 PERC TEST RESULTS t ! I• ' r PRECAST SEPTIC TANK WITH ?1► ; - PRECA'ST LEACHING PITS PERC RATE : � ' J' - CAST IN PLACE INLET AND EL, NO.: SIZE : WHITNESSEO BY : .- • OUTLET T 'S PER TITLE T vv1-t' ' a . , ,+ ) .- BOARD OF HEALTH SIZE : DIA . , • DATE c1 ,= ), L•' ► � ,- DIA . ti PROFILE OF PROPOSED SEWAGE SYSTEM O o SYSTEM DES16NED BY THE TOWN OF — ��--- - REGULATIONS AND STATE TITLE Y FOR SUBSURFACE DISPOSAL OF SEWAGE . SCALE : 1/4y- 1 ONt �� - r o N .6 . 2• ALL TAPES SHALL BE SCHEDULE 40 P.Y.C. SEWER PIPE ' = �'� o SLOPED 1/4" PER FOOT EXCEPT FOR 2. ALL PIPES SHALL BE SLO 0 �, � THE FIRST 2 FEET OUT OF THE 0 / 8 WHICH SHALL BE LEVEL S.. OES18N FLOW 4 BEDROOMS AT 110 GALDAY PER BR . z . GAL/DAY SEPTIC TANK SIZE 4- X GAL. g - USE S: 6AL. w/ - GARME DISPOSAL , �' LEACNINI SYSTEM: USE a - ti t j ��' 4 O 4 ` EFFECTIVE AREA: SIDE %�EFF , E BOTTOM . . nw. .. nwww.w•.n �t t TOTAL FLOW , -4 wo ► �� t � , ,-j�. _ TOTAL REQ'0 FLOW 4 X 4-4 <:�� W/ GARBAGE DISPOSAL J W - `F ' RESERVE FLOW 6AL/DAY REFERENCE PLANS A , w APPROVED BY : BOARD OF HEALTH DATE : r- SITE AND SEWAGE PLAN r r PROPERTY OWNER : N of ,a FOR- /� ►c ,R . . .-_ PAU L ss9c 9WSlt#Ali �' BE O ROOM 31 M GM 1`�►W'( C!Pw1L.I 1 wd G o` • _ A. LIEIERMAN < 1 k P\ M IT Ste. 23t3] ti LOT-'2, 9 TScR`�p Ja fG•5. �o DA TE f ' r --- 6 ..* Hai LAND 1 W ILL ►A 1.l E 4 E V1 M1 Ate! ya: 2 3 S,1 1 '1 ,`• _