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HomeMy WebLinkAbout0010 COLONIAL FARM CIRCLE - Health (2) 10 COLONIAL FARMS CIRCLE,'MAkS7 MILLS T v k s� Feb 25 04 07: 16p David S. Martin 508-420-15® l p. 2 k� i i � a � �a, m 0 OJ �- i m O Lf� 4 LD cAq- A IU IL iL r 0 0 LP cu LL TROY WILLIAMS L a SEPTIC INSPECTIONS Certified by MA Department of Environmental Protection (508) 385-1300 19 Hummel Drive South Dennis,MA 02660 UV COPY COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 TRUDY CORE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Cottttttissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATIONProperty Address: /0 C v Fa✓wr C r"t' Name of,Owner �� +• rO y. M ri.v-S 7zo.. J lf4 I(.5 - Address of Owner: Date of Inspection:A 1,.e/9 F /{��✓I�H S (4/�.��� Nt ca . Name of Inspector:(Please Print) Troy Williams 1 1 am a DFP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) O S18 Company Name: Troy Williams septic Inspections Mailing Address: 19 Hummet'Drive, So. Dennis MA 02660 Telephone Number: (508) 385-1300 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the'information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes . Conditionally Passes r. Needs Further Evaluation By the Local Approving Authority _ Fails Inspectors Signature: ��,�-y 'L./.( �-i..,� Date: -ql-? The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable, and the approving authority. NOTES AND COMMENTS Although system meets the minimum requirements set forth by the Massachusetts Department of Environmental Protection,certification is not to be construed as a guarantee of future workin Iddon of system, piping or components. This inspection represents the conditions of the system o e ego r Inspection notea above. FF 1 A, � ' to 1 �999 C'V �'c,`' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: owner: 10 Colonial Farm Circle,Marstons Mills,MA Date of Irupection: John&Judith Troy February 2, 1999 INSPECTION SUMMARY: Check A. B, C, or D: A. SYSTEM PASSES: VI have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health, will pass. Indicate yes,no,or not determined-(Y,N,or ND). Describe basis of determination In all instances. If "not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20) years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked, structurally unsound,shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more 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): broken pipe(s) are replaced obstruction is removed revised 9/2/98 Page 2 of II SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) P1W,1Y Address: 10 Colonial Farm Circle,Marstons Mills,MA Owner: John&Judith Troy Date of t—p--t-: February 2, 1999 /C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: 'A 119 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. 11 SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic-tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public wateir supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system.and the SAS is less than'100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER rev ; Sed' 9 i2/.9� PaRr t of I I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO N FORM PART A CERTIFICATION (continued) 10 ColonialiFarm Circle,Marstons Mills,MA i Property Address: John&Judlth Troy Owner: February 2,'I1999 Date of inspection: I D. SYSTEM FAILS: N14 You must indicate either'Yes" or ";No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due-to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 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 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 feat 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: Al/9 You must indicate either "Yes" or "No" to each of the following: The following criteria apply;to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: i 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 It of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. I I 1 revised 9/2/98 Ngc4 of „ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART 8 CHECKLIST j Property Address: 10 Colonial Farm Circle,Marstons Mills,MA owe: John&Judah Troy Date of Inspection: February 2,'1999 i Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant,or Board of Health. None of the system components have been pumpe&for-at least two weeks and-the system has been•recei rates during that period. Large volumes of water have not been introduced into the system recently or asp part of this flow inspection. Y 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. Y _ The system doe's not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. 3C _ All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manhole*weFe uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum. / The size and location of the Soil Absorption System on the site has been determined based on: Existing information. For example, Plan at 8.6.1-1. yC _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance Is unacceptable( (15.302(3)(b)) _ The facility owner(and occupants,if different from owner) were.provided with information on tha.propermaintanaace of Subsurface Disposal Systems. { revised 9/7 /U8 Page 5ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: 10 Colonial Farm Circle,Marstons Mills,MA Date of Inspection: John&Judith Troy February 2, 1999 FLOW CONDITIONSRESIDENTIAL: Design flow: //0 g,p,d./bedroom. Number of bedrooms(design): Number of bedrooms(actual): Total DESIGN flow yyo Number of current residents: 02 Garbage grinder(yes or no): yC'S Laundry(separate system) (yes or no):A10; If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use (yes or no): ND Water meter readings,if available(last two year's usage(gpd): �8 = 93,60U G a�(„ S g 7 = ��� o o0 �r a /sty•.t Sump Pump(yes or no):_�0 Last date of occupancy: d`c..!j•)•e-6A . COMMERCIAL/INDUSTRIAL: A/�Iq Type of establishment: Design flow: gpd (Based on 15.203) Basis of design flow Grease trap present:(yes or no)_ Industrial Waste Holding Tank present:(yes or no)— Non-sanitary waste discharged to the Title 5 system: (yes or no)— Water meter readings,if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of inforr ation: 1 �[.2--�`�ri, r�, a, t i h 77 G.V G � l!r S�-` tJ-� /�G�rr. s-rya. 6 J —Tr �H e„��•, �oa„�/ ' System pumped as part of inspection:(yes or not /�/d If yes,volume pumped: gallons Reason for pumping: TYPE PF SYSTEM /L 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) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components,date installed(if known) and source of information:. —p�.-r• o-s— �u; 1 f . Sewage odors detected when arriving at the site: (yes or no) N� revised 9/2/98 raRed ,rri =;f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: owner: 10 Colonial Farm Circle,Marstons Mills,MA Date of Inspection: John&Judith Troy BUILDING SEWER: February 2, 1999 (Locate on site plan) i Depth below grade: 7 ` Material of construction:_cast iron­V/40 PVC—other(explain) Distance from private water supply well or suction line /V/i9 Diameter y f, Comments:(condition of joints, ventin , evidence of leakage,etc.) -Alt a c c/I G%car �� fine 674 iMsi���✓t SEPTIC TANK- (locate on site plan) Depth below grade: r 1n4S r S h4L4- 4-v Material of construction:Zconcrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age ls.age confirmed by Certificate of Compliance_(Yes/No) Dimensions: 7�k// 'X Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: I r' Distance from top of scum to top of outlet tee or baffle: 6 r� Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: :' a t-S✓ ; /4-. Comments: (recommendation for pumping,condition of inlet 4!nO outlet tees or baffles,depth of liquid level in relation to outlet invert,strticturaFirttegrity, evidence of leakage,etc.) w c r y w r ' ,, o ,�� Al" 4 c L cc r �a o G/ . �� i�,. c G►., , i c�v c_v w. 0....dt ✓ i 1 . —1-,v�/u. S 6d,lob LQ lG i H S GCtik fq A �. O 1�' '� ✓ G.,7 V✓Yt C/l GREASE TRAP:�(/,9 0. b .►+t, (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) revised 9/2/98 Page 7ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) .I.operty Address: O Mner: 10 Colonial Farm Circle,Marstons Mills,MA Fate of Inspection: John&Judith Troy February 2, 1999 FIGHT OR HOLDING TANK:A/�(Tank must be pumped prior to, or at time of, inspection) .1locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensions: Capacity: gallons Pesign flow: gallons/day ,'arm present Alarm level: Alarm in working order:Yes No- -Date of previous pumping: •Comments: - condition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: ",j "�Omments: $no .if level and distribution is equal,evidence of solids carryover, evidence of leakage into or out of box;etc.) 9-100,+c . (-j PUMP CHAMBER:_,A///q ;i�cate on site plan) .� i*zimps in working order:(Yes or No) E Warms in working order(Yes or No) 'a»+f:gmments: tinote condition of pump chamber,condition of pumps and appurtenances,etc.) 1'1_vised 9/2/98 P.gf xofII t f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: owner: 10 Colonial Fann Circle,Marstons Mills, MA Date of Inspection: John&Judith Troy February 2, 1999 SOIL ABSORPTION SYSTEM(SAS):LZ (locate on site plan, if possible; excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: r leaching pits, number: 6 X-C leaching chambers,number:_ leaching galleries,number:_ leaching trenches,number, length: leaching fields, number, dimensions: overflow cesspool,number:_ Alternative system: Name of Technology: Comments: (n to condition of soil,signs of hyr�rauli failure,level of ponding, damp soil, condition of vegetation, etc.) a, W c� S �d✓�. L ter. 1. o' f / W o. �o✓"c� 0 ge— A— t P A r.72 0LtJ G.J v w .r c� cr t c.✓� I i-)1, w c. 4--.v w o-S r' -j �i� �i -A Al,CESSPOOLS: A/ (locate on site plan) r -� cry �Ycs 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 soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate on site plan) Materials of construction: Depth of solids: Dimensions: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revised 9/2/98 Page 9of II i i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: 10 Colonial Farm Circle, Marstons Mills,MA Date of Irupection: John&Judith Troy February 2, 1999 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) Fr U n h C. lSooy4f o T�►t. 3� i 41 l � l . � �x� � �<<. �� P: -►-tea i i revised 9/2/98 Page 10 of I I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(corrtirxiedl Property Address: Owner: 10 Colonial Farm Circle,Marstons Mills,MA Date of Inspection: John&Judith Troy February 2, 1999 NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited w A 1/8,G Observation Wells checked 20 N6 C3 9 4cJ Groundwater depth: Shallow Moderate Deep V/ SITE EXAM Slope / Surface water Check Cellar Shallow wells Estimated Depth to Groundwatera2(Feet Please indicate all the methods used to determine High Groundwater Elevation: V/Obtained from Design Plans on record Observed Site 1Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators,installers V/ Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) � 4A _. ,S(hOr,Jtr�l ho w�cfw �o�...�. �a 1 Qcpf� /6 ,0 w ��vSYr.ci. r �� ^,•� o� ii.3�o��ifsva,� w4 s o�,Pj . Qr cJ ; a 4 1 o /,� �^r✓(� a ✓-� t c� o a. �!J (H h � �j o WGc� s-t v G✓ca.y-Li —Cj aJ r � , `r/rc�rA.� eft✓� 1 v h � (�,.., S �o�✓ Poy,d 1<� 1 0, S 0 /occj. 4-�r� (n o 4' o c c. 4- e,d r h i y Y'D J H fi+.-� c✓ ( �(. revised 9/2/98 Page II of II Y TROY WILLIAMS SEPTIC INSPECTIONS A Certified *MA Department of Environmental Protection R rlc�ita:"� - (508) 760-1819 40 Old Bass River Road F APR 1 ,1 1996 South Dennis,MA 02660 fkPdifGrg(M�, Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection William c nor F.Weld Trudy Cox* Argoo Paul Celiuodi sewwwy 11 KK Davld B.Struhs canwrAnwWf SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A _ ��C,,r�ERTIFICATION Property Address �/0 Cc�o ti; �,I FoLo '`. .rrrNrs A)o Address of Owner. Date of Inspection: y1S 6 (If different) c / Name of Inspector -77oy i_/' '';N ^y JCl H1 G . Company Name,Address drrd Telephone Number. SEE G• bd41e . CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: asses — Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails inspector's Signature: A / Date: The System Inspector shall submit a copy of/this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A B, C, or D: AI 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. BI SYSTEM CONDITIONALLY PASSES: /v/"'q One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes. no, or not determined (Y. N, or ND). Describe basis of determination in all instances_ If"not determined", explain -by not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or ex-filtration, or tank faihue is imminent The system will pass inspection if the existutg septic tank is replaced with a ponforming septic tank as approved by the Board of Health (re­seC 11/03/(?S) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: C-o �v n`.,, Fa,r r, Owner. (^J h e tM�n to Date of Inspection: B)SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more 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): broken pipe(s)are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: /V1,4 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 HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING 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 within 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 that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. 3) OTHER (revised 11/03/95) 2 SUMURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: /a Go'o�• u ( Fa✓�., Owner. w:�h Date of Inspection: L r D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMA 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 effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. — Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. — Liquid depth in cesspool is less than 6"below invert or available volume is leas than 1/2 day flow. — Requite pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped — Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. — Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. — Any portion of a cesspool or privy is within a Zone 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 leas 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,i volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria applyi to large systems in addition to the criteria above: The system serves a facility!with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: — 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 I — 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 com fiance l with the dwa ter requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for furthe r infor-mationatment program (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Adareas: /o G,l c) cj,j Owner. GJ ti k.4 l�h Date of Impaction: `115,/ Check if the following have been done: lumping information was requested of the owner,occupant,and Board of Health. _ZNone of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. 2Aa built plans have been obtained and examined. Note if they are not available with N/A. _Zl&facility or dwelling was inspected for signs of sewage back-up. _ZThe system does not receive non-sanitary or industrial waste flow _ZThe site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. ZThe septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. ZThe size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. The facility owner land occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ,,,„ / / SYSTEM INFORMATION Property Address: /U l D 1 ,1 P'l l A ' �0.✓N� Owner. Date of Inspection: RESIDE TIAL: FLOW CONDITIONS Design flow: Jt�1loj, Number of bedroom,: 41 Number of current residents: a Garbage grinder(yes or no):_VO Laundry Connected to system(yes or no):_&S Seasonal use(yes or no): N 66 Water meter readings, if available:_ 9 s = 02 UJ Last date of occupancy: D� C v`p ck COMMERCIAL/INDUSTRIAU Type of establishment: Design flow:_uuona/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yea or no)_ Non-aanitary waste discharged to the Title 5 system: (yea or no)_ Water meter readings, if available: Last date of occupancy; OTHER; (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: L / / V �N�b In�i i l•. >� ` � G�- m pumpea ae part of inspection: (yes or no)/Vd If yea, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM Septic tank/distribution box'soil absorption system Single cesspool Overflow owspool Privy Shared system (yes or no) (if yea, attach previous inspection records, if any) Other(explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: i Gl S 6u, '1 Sews,ge odor's detected when arriving at the site: (yea or no) j',I 0 (revised 11/03/95) (i r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: b Go o�.;a ( f—o-r•� Owner. c1 k, Date of Inspection: y/s-/�6 SEPTIC TANKV (locate on site plan) Depth below grade:,/ 1 u s r'S Material of construction:, concrete_metal_"--other(explain) ` Dimensions: Sludge depth: 2 Distance from top sludge of slu 19 to bottom of outlet tee or baffle: Scum thickness: IV61V� Distance from top of scum to top of outlet tee or baffle:/No S<-­j Distance from bottom of scum to bottom of outlet tee or baffle: &a S c vJ AI 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.) u—dx 'lot c ,-ok c✓. t o S i �, f c o. b✓ r—a „ a� o �. o rc �/ u.. : n GREASE TRAP ,!V/4 (locate on site plan) Depth below grade: Material of construction: _concrete_metal_FRP_other(e:plain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or bane: Distance from bottom of scum to bottom 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.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Address: 10 <�A i O to,cj Owner. IW; H k Date of Inspection: �'6 TIGHT OR HOLDING TANI:_y�i9 (locate on site plan) 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: V (locate on site plan) Depth of liquid level above outlet invert: Gc�e Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) 10— G. _lf& A L,✓led-- I c. , J aai /K •> Jl//` .. L o —ck G✓ ®i S f^r. T7u H �D 60 7 ti �^-_-k.5 C /7-S PUMP CHAMBER:/ / g (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 11/03/95) 7 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: /6 L6 /e�,`.c, k, Owner. W k, Date of Inspection: y/r/y6 SOIL ABSORPTION SYSTEM(SAS): ✓ (bcate on age Plan,if posab1e;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: leaching pite, number: JL0�..c , leaching chambers, number._ Ong galleries, number- leaching trenches, number,length: leaching fields, number,dimensions: overflow cesspool, number: Co uts: (note condition of soil, signs of hydrayllic failure, level of ponding, condition of vegetation,etc.) v, 1/ CESSPOOLS:L1 (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: Mow(cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:1,q (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note oondition of soil, signs of hydraulic failure, Level of ponding, condition of vegetation, etc.) (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: /0 o. c1 ( �o.✓vr-, C:r. Owner. Gt); k 1 Date of Inspection; SKETCH OF SEWAGE DISPOSAL SYSTEM: indude ties to at least two permanent references landmarks or benchmarks locate all wells within 100' as ►a isovy�l 7�` yb� � 36 53 �7 pax . 02 — 6 'X6 /Le� �G, P:�s DEPTH TO GROUNDWATER ' Depth to groundwater: feet _ adjusted high groundwater level method of determination or approximation: y c , < A, w 6, o O��c �ocs ion tiL w T �, !ny [.J�� �✓ 9 v t rl TOWN OF BARNSTABLE LOCAVON Z D L4 to 1, C-,r • SEWAGE# VILLAGE 4^ • M ' �� S ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY �� y LEACHING FACILITY: (type) X G ��t`s (size) C—) NO.OF BEDROOMS L I BUILDER OR OWNER 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 onisite or within 200 feet of leaching facility) Feet Edge of Wedand and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by � 3Y yol 3� TOWN OF IBARNSTABLE LOCATION LoT*`l Z-L: Ce�'.d��d�6 'C`�a`^^ 6a'4WAGH VIL LAGE_ STL�I)SIL ASSESSOR'S MAP & LOT _ INSTALLER'S NAME & PHONE NO. SCe�t-L_ SEPTIC TANK CAPACITY-- 1 LEACHING FACILITY:(tVpe (si?-e) 10 NO. OF BEDROOMS - __PRIVATE WELL OR UBLIC WATER j -- BUILDER OR OWNER K.,)!s C, _ DATE PERMIT ISSUED: DATE CO?:S.PLIANCE ISSUIED: VARIANCE GRANTED: Yes—----No r � vV Q � 60 1 (� TOWN OF:BARNSTABLE LOCATION L,6'-� IZ VIL-LAuE ASSESSOR'S MAP 6z LOT :9 INSTALLER'S NAME & PHONE NO. b(0�0II 171 3 )06 EPTICTANKCAPACITY 1, 000 ,� �lo�► p 4EACHING FACILITY:(type) �' G'`�' �� (size) e i p'�'NO. OF BEDROOMS PRIVATE WELL O PUBLIC WATER ©`BUILDER OR OWNER 7 r1 U`,� '�►S DATE PERMIT ISSUED: C�Gv�az-C 19 yiro DATE COMPLIANCE ISSUED: a VARIANCE GRANTED: Yes No �/ i - . C,df ��Z .N i 3 ' � ' 1 . . . �� i ; / / 0/r���"� . �tr. . ° . '� ` 7 61 Fes$.....75�Dv....._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 71ci /..............OF....... ....................................... Appliration for Dispoaa1 Njarkii Tatuitrnrtion Prrutit Application is hereby made for a Permit to Construct (Z or Repair ( } an Individual Sewage Disposal System at: 6----------- ------- ......Pj....................................... l Location-Address r No. _�i.g*1l /YI?fir: - cep.!?%1 G?t'2. . ... .............................._..... Owner Address �Instalier Address Type of Building Size Lot.1Z_.`V&)----------Sq. feet U Dwelling—No. of Bedrooms.__ ......__ _Expansion Attic ( ) Garbage Grinder ( ) PL4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) G4 Other fixtures ----------------------------•••. . W Design Flow........5L5.. ........................gallons per person per day. Total daily flow..........3_30.........................gallons. W Septic Tank—Liquid capacity/_e.'00__gallons Length............ Width..&...._..... Diameter................ Depth................ x Disposal Trench—NTo. .................... Width-------------------- Total Length.................... Total leaching area._______---.------•-sq. ft. Seepage Pit No-------I------------ Diameter........9......... Depth below inlet.....6........... Total leaching area )aO--_----sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ~' Percolation Test Results Performed by.-6J-M....... h........................ Date....................._______--------_--- aTest Pit No. I.....;�.......minutes per inch Depth of Test Pit.................... Depth to ground water_.--_-.-_-__--___---- (i Test Pit No. 2................minutes per inch -Depth of Test Pit.................... Depth to ground water........................ --r--�•-• •---•-------•••.. ...........•---••--_. .....---- ---- ................................... ----•--- O P, _ - Description of Soil--C�--._.� ---1.A -�1.:,1.�t,�.-------•-------------------------------------------------•-----------------------------.........-- - x q_. . ► .rJ� .r ,.......--- !--:-------.,.�� ,-ate �1 �.t =� 1 /t.t�._�K/1dGt _r- U / {)gyp �C1C �1 r_t_lFd ' ..•-l.3!----ld-�l.__.!Li-Q f Gt�l111•_. .liht i t --- ---------------------------- ........... U Nature of Repairs or Alterations—Answer when appli le----------------------------------------------------------------- -----------------------------------•----- --------•------------------------------------------------•-------------------•------................................................................ Agreement: ^- J The undersigned agrees to install the aforedescrib Indi idu Sewage Disposal System in accordance with the provisions of I : ..,•. ; of the State Sanitary C d �-�Th n' geed furti:er agrees not to pl/etsystem n operation until a Certificate of Compliance has be ssd b t d of health. �Sign --- -----------------------•------•-•--------------.....-----..........---•--•--- -- ..---•--•------- ate. ApplicationApproved BY -------••-•---•-• ---••---- -----------------------------------------------•-•--. •-------- •/'`' �� Date Application Disapproved for the following reasons:....................................................................................•--.._................._.__ .....................•------••-•--•---------•--------•------•-----------....--------............---...-----------•------....-----------------------------------------•-- Date PermitNo......................................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS fl ---rr�� BOARD OF HEALTTH ............r,',.7.3,�ta�..........OF....... 1�1.!a,fx1,! .i .................................. Trrtif iratr of Tomplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed 06 or Repaired ( } bY......K='Q.l .......R.t_�- ------------------------------- .................................................. � � /� In alley �y'�� �i at....40 f�` ,Q_1l/t :� ------ (:•L�=-�. lC..... �1�1'J l /L 1._�Lx.�l has been rnstailed in accordance with the provisions of i_L i 1E j of The State Sanitary Code as described in the {• application for Disposal Works Construction Permit No......................................... dated-.---------------------------------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE............................ �J.d .......................... Inspector...................... 1 0......................................... f�` THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH T4,21!(..I.Y1 ...........O F.. GS. ? ?Jl l. .l. ......................................... > � Disposal Work. Taonstr tion rrmff Permission is hereby granted.....Y�ItL!Y.A......)I! to Construct QO ) or Repair ( ) an Indivi ual Sewage isposal System `�,� at No•-�?f-•---../X....... f.�?. /.�►'�s_rth..--....J' '.I a2.----. -r e-------------------/` ifG r 2 ......�l�J„©.............. Street as shown on the application for Disposal Works Construction Permit o..................... Dated.......................................... � - fi - --------------•---------------- FATE_ ....0a!�J�t ....... �..t 1.............. Board of Health FORM 1255 HOBBS & WARREN. INC.. 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