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Home My WebLink About0183 SHOOTFLYING HILL RD - Health 13'SHOOTFLI'ING HILL R A r 0 o 0 o o ° II Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 183 Shootflying Hill Road Property Address Linda Girard Owner Owner's Nameinforma ----- --- —_ require for is West Barnstable _ Ma 02668 12/18/2019 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 tillingng out A. Inspector Information Sly M 319 out forms on the computer, Sean M. Jones use only the tab key to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use the return 1. Company Name _.._ ._._...__...__.� key. 74 Beldan Lane Q Company Address Centerville Ma 02632 CitylTown State Zip Code =t 774-2484850 smjonestitle5@gmaii.com, SI 4522. sean@smjonestitle5.com 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 16.000); 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. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 12/18/2019 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 flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to 9Y P 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. t5insp.doc•rev,1/efMill Title 5 Official inspott on Form!Subsurface Sewage Disposal System•Page 1 or 18 Y Commonwealth of Massachusetts k" - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments zl—l183 Shootflying Hill Road _.____ Property Address Linda Girard Owner Owner's Name information is required for every West Barnstable Ma 02668 12/18/2019 page. Cityrrown 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 property located at 183 Shootflying Hill!Rd West Barnstable is served by a Title V septic system consisting of a 1000 gallon septic tank, distribution box and a 1000 gallon precast leach pit. The system was found to be in proper working condition 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): 15insp.doc•rev.7/2612018 Tille 5 official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 I Commonwealth of Massachusetts _s Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 183 Shootflying Hill Road Property Address Linda Girard Owner Owner's Name information is West Barnstable Ma 02668 12/18/2019 required for every C /Town page. itY State Zip Code Cate of inspection C. Inspection Summary (cont.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumpstalarms 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 16.303(1)(b)that the system is not functioning in a manner which will prrotect public health, safety and the environment: t5insp.doc-rev.7/26 018 Title 5 Official Inspection form:Subsufface Sewage Disposal System-Page 3 or 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 183 Shootflying Hill Road Property Address Linda Girard Owner Owner's Name Information is West Barnstable Ma 02668 12/18/2019 req9euired for every Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cant.) ❑ 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 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 ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev,712612018 Title 5 Official Inspection Form'Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts � - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 183 Shootflying Hill Road Property Address Linda Girard Owner Owners Name information is West Barnstable Ma 02668 12/18/2019 required for every page. Cftyrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal conform 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.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® 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.doa•rev.7PL=18 Title 5 Official Inspection Forth:Subsutface Sewage Disposal System•Page 5 or 18 Commonwealth of Massachusetts Title 5 Official Ins •, � pection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 183 Shootflying Hill Road Property Address Linda Girard Owner owner's Name Information is required for every West Barnstable Ma 02668 12/18/2019 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 threat, or answered"yes"to any question in Section CA above the large system has failed. The 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 aff inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ Z Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were.the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the,field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] t5insp.doc rew 7120018 Title 5 official Inspection form,Subsurface Sewage Disposal System•Page 6 of is Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 183 Shootflying Hill Road Property Address Linda Girard Owner Owners Name Information is West Barnstable Ma 02668 12/18/2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 gpd Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® 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 ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail Sump pump? ❑ Yes ® No Last date of occupancy: current Date t5imp.doc•rev 7rM2018 Title 5 Official lnspedion Form.Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts tz:VTitle 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �)'k 183 Shootflying Hill Road _ — Property Address Linda Girard Owner Owner's Name Information is West Barnstable Ma 02668 12/18/2019 required for every page City/Town State Zip Code Date of Inspection D. System Information (cunt.) 2. CommerciaUlndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No 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: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? ------ Reason for pumping: t5insp.Qoc•rev.71MM18 Title 5 d8ici2l Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 183 Shootftying Hill Road Property Address Linda Girard Owner Owners Name information is required for every West Barnstable Ma 02668 12/18/2019 page. CityrFown State Zip Code Date of Inspection D. System Information (cunt.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)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: original system installed 1993 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 3 feet Material of construction: ❑cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): ` Joints in good condition, no leakage, vented through roof. t5insp.d=-rev,7/26/2018 Title 5 official Inspection Form.Subsurface Sewage Disposal System•Rage 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 183 Shootflying Hill Road Property Address Linda Girard Owner Owner's Name information is required for every West Barnstable Ma 02668 12/18/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cunt:) 6. Septic Tank(locate on site plan): Depth below grade: 2.5 9 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 Dimensions: 1000 gallons Sludge depth: 5" Distance from top of sludge to bottom of outlet tee or baffle 3' 2" 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 10ts ---- How were dimensions determined? Opened covers and took _ . .._,_ _... _.._._.._ __._..... ._ measurements Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance.water level was even with outlet, tank was not leaking and was structurally sound. Inlet cover is on a riser t3lnsp.tloc•rev.TQW2018 Title 5 Official lnspeaton Forth:subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .r 183 Shootilying Hill Road Property Address Linda Girard Owner Owners Name information is West Barnstable Ma 02668 12/18/2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): 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): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: -- Capacity: gallons Design Flow: gallons r da 9 per Y t5ttlsp.doc•rev,71=18 We 5 Official Inspection form Subsurface Sewage Disposal System Page 11 of 18 Commonwealth of Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 183 Shootflying Hill Road Property Address Linda Girard Owner owner's Name Information is required for every West Barnstable Ma 02668 12/18/2019 page. Cltyrrown State Zip Code Date of Inspectionw " 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): 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.): Distribution box was functioning as intended. tSinsp.doc-rev.70018 Title 5 Official Inspection Form:Subsurfsoe Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts - r - Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .� 183 Shootflying Hill Road Property Address Linda Girard Owner Owners Name information is west Barnstable Ma 02668 12/18/2019 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.): *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: ® leaching pits number: 1 ❑ 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.dw•rev.7=2018 Us 6 Official Inspection Foos:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 183 Shootflying HIII Road Property Address Linda Girard Owner Owners Name infonsition is West Barnstable Ma 02668 12/18/2019 i ..red for every _.......�____:-.._.._-... pageCityrrown 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.): Leach pit was located and excavated. Pit was found with 4' standing water and a stain line 2" higher. 12. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert ---- —--- Depth of solids layer — Depth of scum layer ------- -- — Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins .dc•ray.712MI8 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 183 ShootflyinR Hill Road ProPeRY Address Linda Girard Owner Owners Name Information Is West Barnstable Ma 02668 12/18/2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) 13. Privy (locate on site plan): Materials of construction: -- .......- — Dimensions Depth of solids -- Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5lnsp.doe•rev.7188l2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 183 Shootflying Hill Road Property Address Linda Girard Owner Owner's Name information is west Barnstable Ma 02668 12/18/2019 required for every C !Town page itY State Zip Code Date of Inspection D. System Information (cunt.) 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: Z hand-sketch in the area below ❑ drawing attached separately .35' a 'r'�2. 3216 ( z 3Z Z A.3 37 3 15insp.doc•rev.7YZ812018 Title 5 Official Inspection Form;Subsurface Sewage Dispesal System•Page 18 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ' 183 Shootflying Hill Road Property Address Linda Girard Owner Owner's Name Information is West Barnstable Ma 02668 12/18/2019 required for every page. City/rown 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: 12'+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_._._..._ - ❑ 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) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater was established by accessing town of Barnstable groundwater contour maps. Before filing this Inspection Report,please see Report Completeness Checklist on next page. 15insp.doc•rev.7f28PZ018 Title 5 official Inspection Foam:Subsurface Sawage Disposal Syslem•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ��-�, 183 Shootflying Hill Road Property Address Linda Girard Owner owner's Name Information is required for every West Barnstable Ma 02668 12/18/2019 ---------- page. City/Town 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 t5insp,doc•rev.M6016 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 18 of 18 Commonwealth of Massachusetts Executive of Environmental Affairs f - 9"0 DEP Department of Environmental Protection -96' !` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A, CERTIFICATION Property Address: 183 S hoot Flying H ill. 'la1 a. Address of Owner: Anthony&E ilee Martin (if different) Po Box 172, Osterville Ma. Date of Inspection: 04/17/96 Name of Inspector: Michael D eD ecko Company Name, Address and Telephone number: Atlantic Environmental P.o Box 2384 - M ashpee Ma 02649. Tel: (508) 4771420 CERTIFICATION STATEMENT 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 -X-- Passes ---- Conditionally Passes ---- Needs further evaluation by the local Approving Authority ---- Fails r Inspector s Signature: c L Date: 04J19196 The system Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. I f 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 or the Department of Environmental Protection. The original should be sent to the system owner and copy sent to the buyer, if applicable and the approving authority. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 183 Shoot Flying Hill Road, Centerville Ma. Owners : A. Martin Date of Inspection: 04/17/96 INSPECTION SUMMARY: Check A, B, C, or D A) SYSTEM PASSES: --x-- I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CM 15.303. Any failure criteria not evaluated are indicated below 8) SYSTEM CONDITIONALLY PASSES: ---- 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 determinate CY,N,or ND). Describe basis of determination in all instances. If"not determinated", 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 septic tank is replaced with a conforming 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 PP (s)i e . The system will pass inspection if (with approval of the Board of Health): ----- broken pipe(s) are replaced ----- obstruction is removed SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address : 183 Shoot Flying Hill Road, Centerville Ma Owner : A. Martin Date of Inspection: 04/17}96 C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: --- Conditions exist which require further evaluation by the Board of Health in order to de- termine if the system is failing to protect the public health , safety and the environ- ment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING INAMANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETYAND THE ENVIRONMENT: ---- Cesspool or privy is within 50 feet of a surface of water ---- Cesspool or privy is within 50 feet of a bordering vegetated wetland or a small marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNC- TIONING INAMANNER 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 aseptic 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 analy- sis 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 notrogen is equal to or less than 5 ppm. D) SYSTEM FAILS: -- I have determined that the system violates one or more of the following failure criteria as defined in 310 CM 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to cor- rect the failure. --- Backup of sewage into facility or system component due to an overloaded or or clogged SAS or cesspool. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 183 Shoot Flying Hill Road, Centerville Ma Owner: A. Martin Date of Inspection : 04/17/96 D) SYSTEM FAILS (continued) -- 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 over- loaded 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 NO T 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 cesspool or privy is within 100 feet of a surface water supply ortributary 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 ana- lysis. 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. I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 183 Shoot Flying Hill Road, Centerville Ma. Owner: A. Martin D ate of I nspection: 04/17/96 E) LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above : The design flow of system is 10,000 gpd or greater Large System and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist : --- the system is within 400 feet of a surface drinking water supply --- the system is within 200 feet of a tributary to a surface drinking water supply --- the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone II of a public water supply well The owner or operator of any such system shall bring the system and facility into full compli- ance 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 Property Address: 183 Shoot Flying Hill Road,Centerville Ma. Owner: A. Martin Date of Inspection: 04/17/96 Check if the following have been done -x.Pumping information was requested of the owner , occupant and Board of Health. --x None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during the period. Large volumes of water have not been introduced into the system recently or as part of this inspection. --x As built plans have been obtained and examined. Note if they are not available with N/A. --x The facility or dwelling was inspected for signs of sewage back-up. --x The system does not receive non-sanitary or industrial waste flow. --x The site was inspected for signs of breakout. -x All system components, excluding the Soil Absorption System, have been located on the site. ---x The septic tank manholes were uncovered, opened and the interior of the sep- tic tank was inspected for conditions of baffles or tees, material of construc- tion, dimensions, depth of liquid, depth of sludge,depth of scum. ---x The size and location of the Soil Absorption System on the site has been deter- mined based on existing information or approximated by non-intrusive methods ---x The facility owners 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 Property Address: 183 Shoot Flying Hill Road, Centerville Ma. Owner: A. Markin Date of Inspection: 04/176196 RESIDENTIAL: Design flow : 136 gallons Number of bedrooms : p� Number of current residents: 0 Garbage grinder (yes or no) : Laundry connected to system (yes or no): Seasonal use(yes or no) : ►)0 Water meter readings, if available- Last date of occupancy : �a cT COMMERCIAL/INDUSTRIAL : Type of establishment: Design flow : gallons/day 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 Val U PING REORDS and source of ir�ormakion� i�CU S kem pumped as park of ins�eckio (yes or no) :... ............ if yes,volume pomped: .................... gallons Reasonfor pumping :............................................................................................................ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1$9 Shoot Flying Hill Road, Centerville Ma. Owner: A. Martin Date of inspection: 04/176/96 TYPE OF SYSTEM •x 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) --- Other (explain)........................................................................................... APPROXIMATE AGE of all components, date installed (if known) and source of information 1):4 .... b.1................................................:........................... ................................................................................................................................................ ................................ Sewage odors detected when arriving at the site : (yes or no).... ..��..... SEPTIC TANK: ... 6 (locate on site plan Depth below grade: .��...... Material of construction: ..K. concrete ......... metal ........ FRP ........ other (explain) ................................................................................................................................................ Dimensions: Sx. .x`�... Sludge depth :..&.......... Distance from top of sludge to bottom of outlet tee or baffle:......:' '.................. Scum thickness :.......0`............. Distance from top of scum to top of outlet tee or baffle: ........... /S.1...................... Distance from bottom of scum to bottom of outlet tee or baffle :.....(k.'.................. Comments : (recommendation for pumping , condition of inlet and outlet tees or baffles, depth of liquid levelei rela' n to outlet invert, structural integrity, evidence of leakage, etc.)...................... N�...IV��.T4�Q ��t......::�' ..° � .. ...!........ .� .. Th.F�-:�:.l..lsl� �!'.A.,.�:�. .�:r:�...C�c�c,`�•,nri. :�:?�...�:_:�::-�:�:�:=:.t.�:a��:=�:�:.:-..�:�E� �- c? . btu c�r?.c� ......lYc..>�► ,.\..r.. tJ c�tt ..t.Fa �Q,!-� .....sn -: �A.i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 183 S hoot Flying H ill R oad, Centerville M a. Owner: A. Martin Date of inspection: 04/17/96 GREASE TRAP : .....ab......... (locate on site plan) 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:....................................... Distance from bottom 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.)........................ ................................................................................................................................................ ................................................................................................................................................ TIGHT OR HOLDING TANKS:....0...... (locate on site plan) Depth below grade:............... Material of construction:........concrete........metal.........FR P..........other (explain).......... ................................................................................................................................................ Dimensions:............................ Capacity:....................gallons Design flow:...............gallons/day Alarm level:............................. Comments: (condition of inlet tee, condition of alarm and float switches, etc.) ................................................................................................................................................ ................................................................................................................................................ J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PAR T C SYSTEM INFORMATION (continued) Property Address: 183 Shoot Flying Hill Road, Centerville Ma. Owner: A. Martin Date of inspection: 04/17/96 DISTRIBUTION BOX:.. 6. (locate on site plan) Depth of liquid level above outlet invert:.....4�� .5,.. Comment: (note if level and dis rib ion equQevi.,.epc of solids carryover evidence of leaks a into r u of ox, etc.). ." !� . ..................... U............t .......................................... ................................................................................................................................................ PUMP CHAMBER:... .... (locate on the site) Pumps in working order: (yes or no)............... Comments: (note condition of pump_chamber, condition of pumps and appurtenances, etc.).................... ................................................................................................................................................ SOILABSORPTION SYSTEM (SAS):...1A6......... (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: .11L.O....)i!c 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 tc.)..cana& ? N... ...Sa1.....c.�.. .. -ct�... ... r�. ............................ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PAR T C SYSTEM INFORMATION (continued) Property address: 183 Shoot Flying Hill Road,Centerville Ma. Owner: A. Martin Date of inspection: 04/17/96 CESSPOOLS:....'..... (locate on site plan) Number and configuration: .................................... Depth-top of liquid to inlet invert: ........................... Depth of solids layer: ............................................... Depth of scum layer: ............................................... Dimensions of cesspool: ...................... Materials of construction: ..................... Indicator of ground water: .................... 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 : ....0.0...... (locate on the site) Material of construction: ................................... Dimensions: ...................... Depth of solids: ................ Comments: (note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.). ................................................................................................................................................ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property►Address : 183 S hoot Flying H ill R oad, Centerville M a. Owner: A. Martin Date of inspection: 04/17/96 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate at wells within 100'. i I A AL 3v:. 9>2 R 3 �L e3 3S D u DEPTH TO GROUNDWATER: Depth to groundwater: Method of determination or app`ro�ximative:. . ................................................................................................................................................ . /2 TOWN OF BARNSTABLE LOCATIONL - SE WA E - VILLAGE ASSESSOR'S MAP & LOT A/ ON INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY 600 LEACHING FACILITY:(type) 6 y i 4 (size) NO. OF BEDROOMS PRIVATE WELL OR UBLIC WATE BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No j/ f � 7 14 No.... Fick 1411--?......... 7 70 THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Appliration for Di ipwml Works Towitrnrtion Urrntit Application is hereby made for a Permit t' C' i p• ( ) an Individual Sewage Disposal system-at: Loat. I c it' ._\ddiess Iot No. Owner -dd-------••---------•------•------ Installer Address d Type of Building Size Lot-.,1 , v._..Sq. feet Dwelling—No. of Bedrooms----- ---------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building -------------------------_ No. of persons........................-.-- Showers ( ) — Cafeteria ( ) Q' Other fixt res ..............•--------------- W Design Flow........... ....----6Pa....--...gallons per person per/day. Total daily.,flow......... .............. ........ -gallons. WSeptic Tank—Liquid capacity,!P°-gallons Length----9--4_ Width.. _ 6-..... Diameter---........ Depth.,$_-......... x Disposal Trench—No. .................... Width....../............. Total Length..........4....... Total leaching area.... /... sq. ft. 3 Seepage Pit No-------I............. Diameter-------&........ Depth below inlet................ Total leaching area.. .....sq. ft. Z Other Distribution box ( Dosing nk ( ) �� Percolation Test Results Performed b .S... i.�/ �.. ......... ---.-.--.-- Date.-.-3�26 -- ...��`......... W y-- f Test Pit No. 1_2 .......minutes per inch Depth of Test Pit:------- ..... Depth to ground water...-.- t... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ,------------------------=.............................................................................. O Description of Soil....... ---••-•-----....� �"1� ------zaa J U ........---P--•-•........................•--•-•-•-••-•-•---••--•---•-•------------.............------. I . I W ---------------------------•--------•----------------...........----•------•----------•--•---•-•--- --•-------•-----------------------•----•---------------••••••---•--•........_••----.......••.....-- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... .....•---•--------•--•---•-•••----•••-•------------•-•---------•--•----------•--•..............•--------••-•--------- ---------------......-•••---•-••-•---------•--•--..................••-••.......... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Co — e undersigned further agrees not to place the system in operation until a Certificate of CompliVceb is ue y the board of health. Signed ... . ---- .................................... Application Approved By --------------- U�.s., +- ---?r�...................-.......... 1.X.—fB... ....... Application Disapproved for the following reasons: .............................................................................. ............................................................................................... ............. ............-- . -- .... ........................................... . ........................................ e• Dace PermitNo. ......................... Issued ............................. . ............................................................... Date ILI No... Flms.....�.. ..n......._. »--� THE COMMONWEALTH OF MASSACHUSETTS /JS/) BOARD OF HEALTH ' TOWN OF BARNSTABLE Appliration for Uiripw ml �ii nrlig Tontitrnrtinn 11amit Application is hereby made for a Permit to C-ns r t o It^p-•i-t- ( ) an Individual Sewage Disposal System at: .. _ -. ...------.. r__ ......... -------------------------------------------------------------- Locst \dd4cs or,Lot No. /�------------- /�j b�?T Tece,....-.ZX..1.. Z�S ..,/� �''� W Owner Address �._..... .....er-••--•..................................• ------•---......... .......d-- ...............................Address --.........................�_.. I 0,Z oa Type of Building Size Lot..,It. U...._Sq. feet a Dwelling—No. of Bedrooms-----------------------------------------._Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------- ----- No. of persons............................ Showers ( ) — Cafeteria ( ) al Other fixtures ------------------------------- - - W Design Flow........... .........gallons per person perjda7,. Total daily"Pow.. 0.......................gallons. WSeptic Tank—Liquid capacitybaO9._galIons Length----8--r' .___ Width b_._.__ Diameter------- Depth....-......... x Disposal Trench-- No. .................... Width................... Total Length..........4........ Total leaching area....................sq. ft. 3 Seepage Pit No.......l............. Diameter.......6-._.____- Depth below inlet... ............. Total leaching area.-e9�3...-sq. ft. Z Other Distribution box (-) Dosing tank Percolation Test Results Performed b YG-S-_. .......... ........... Date.... � ...... .............. ,.� Test Pit No. 1.... ------minutes per inch Depth of Test Pit__.__-..I._4..... Depth to ground water...._`/yq��ee... (14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 ,...•---------------------...................... --------••-•......-----.......----• ------................-••---•••...----••-•-•-•-••...._................. D Description of Soil.....Z.... ................. �Y!m:....... L V .........--•---••---...----•••••••••-•...............•--•-------•--•---•--....._..-•-••••-•••-••---•-••-••-•-------•------•-----•--••-•-•-••--......-----••••---•-••--•---...-•-....--•••-•-------•-•••- W UNature of Repairs or Alterations—Answer when applicable................................_.._.____............_....._.................................. ..•-••_.....--•-........--•.............•••-•••--•-•-•--•...------•----••-----•••-----•---•--•-----•------•....---••••-------•--•---••--•••--•-......•••--•••-••-••••-•-•-•---•••-------•-------•....... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Cod6— he undersigned further agrees not to place the system in operation until a Certificate of Comph ce s b e isZued y the board of health. Signed -- -- . �- --- ---- ----- -- - . .............................-- ....... /..a�-�T? Date Application Approved By .............. ---�� - ... . . ................................ ........ C. ------- Date Application Disapproved for the following reasons: ...... ........................................ . ........... ........................................................... ......................... Issued ..:..................................................... .......... . ............................................................... .. ............ . ................................................................ ................Dare Permit No. qq ........................ ...1...-02 ��...,?. ....... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C�er#ifirate of C�omplianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (?a'-') or Repaired ( ) by .V r 't-x-------------- at ........ ......q..............� .-... _ I``�... . . ........................ ............................. installed in a accordance with of TITLE�5 of M has beencco provisions ise State Environmental Code as described in the application for Disposal Works Construction Permit No. ._---....��... l .?. dated ..._......................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............................... ......_.---------_ Inspector ----- . �QA ._, ---------------------------.------............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Dish oal Workii Tomitrurtinn "rrmit Permissionis hereby granted--------- ........ ----------------•----------------------------------•-------•---•------•-•--- to Construct (x) or Repair ( ) an Individual Sewage Dispos System �! - � /� A at No..... . . .......... r> ^z Q j-�_�_ �..-- r_(--.. S .,rf �� v a Street as shown on the application for Disposal Works Construction Permit N ._«-z�.�_ Dated............................................ -----•-------------- ............ ....................................................... q l Board of Health DATE.......... - ' 1_i ------------------------- V FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS LOCATION �o T -t 511 oo't' r kk; {.. A._IL/h' — _ NO. VILLAGE_ _ `�` _ —_ DATE 'Z -6c,- E3 APPLICAI`?TehZLI (20t., �C , -- FEE ADDRESS d ( _ ab�e TELEPHONE NO. (Non-refundable ENGINEER C) :� GT,<r k' _�' l/N C_ TELEPHONE NO . 4- Z. 4 7 DATE SCHEDULED—. ( , `Z,(o�( Qj a(, (Applicant' s signature) - ASSESSO IFMIAP & LUT NU: A'A SOIL LOG SUB-DIVISION NAME DATE' TIME , EXPANSION AREA: YES I�<. NO - C. r..i.�,'� ENGINEER TOWN WATER PRIVATE WELL _ A,Ck�Oh BOARD OF HEALT Jr fv. �yI Lc-,a ►1 ( EXCAVATOR SKETCH: (Street name, etc. , (limensions of Iot., exact location of test holes and percolation tests , locate wetlands in proximity to test holes ) NOTES : 9o.Ob in y p o N h ti 44 PERCOLATION RATE: 2 ell 'PEST HOLE NO: ELEVATION: g7. 0 TI;S1' HOLE 140: _ ELEVATION: 1 To Sri 1 _-- 2 5 A 151;l --Z S4 � 2 ---- 5 � n, �� 5 6 --- 7 t- 7 S clad B _..._..__. . 10 10 l.t 11 ------ 12 12 13 13 14 /7¢ 14 -- 15 15 --- - 16 Alo 1. Ila'Iir 16 _ SUITABLE FOR SUB-SURFACE SEWAGE, : LEACHING FIELD EACIIiNG PITS y LEACHING TRENCHL;S L— UNSUITABLE FOR SUB-SURI'ACE; SEWAGE . REASONS : NOTE: ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED ON PE'RC TEST APPLICATION ORIGINAL: COMPLETED IN ENTYRI?'I'Y I3Y P . E . AND RETURNED TO _;3OARD OF HEALTH COPY: RETAINED BY APPLICANT .� t: Lor '��b•rye„ i2'Der.M:Lwc 11 P�'f P � 1 D�sr•Bo'- � N �000 6,AL+CoNL SePTic TANK \ 1 eoPp�� ;o o 3�EDRooM 4"e o� O !`� tV 3I� � vim= 5��• °° � �� - �S�D LO ��? � y 4��s��OkA�ECG pONA�p C{�,FPEL�TT I -6 p� V ASS. .NoS �ENc-�R AS%C• INc �jCAI-E P- 5 77 D I0 low of " C i� O�sr..Bgc. e ' 93.5 GFr• DtAM, 133'z I Qoo(�a�, !�L•S LA4 aCoNP,T. SeP+te. Tq n k f3,D A A � Bor• P�-t E�ti/ /¢ sherd s�orre o L.D 6,eo BUD t 8-7.0 -T-bF'solL Bsol� R. RCoL,a.Td�d�l RA'r�: Z M/Nll1V G 1-� DRO P TEST PEJZF'ot ED tit Pt 2c �, t 9 8 �EAcIf4'3CapRootis x Ito GP� 3 3 42 6V O GARBA46 DISPOSAL USEIpOO �AC..SEPI'ICT�/k 1�oN •� CAPACl'ry RROvIpp- p 3 l3o-r-r wA -rr z� o 81,0 pe. o `E7Z,� SIDES `7Too �z .s - s�sGPD ��bk` -r0TA1- CAPAGITj PROVIpap (c7$ CPD I oTE— D �5POSAf:. J1(ST � D�sfcTNED IN ACLoRDANCS V`! ) Tf4 PROVISIONS O.F Cop= . CA PP ELL-E-FT I LOT rI2 174- 9 Sa00-T F'LYiM4 ALL E,, e N sr a, E �? S-7 w FORM 11 - SOIL EV UATOR FORM Page 1 of 3 No. F-# 8-711 Date: (0Iij 16 Commonwealth of Massachusetts Massachusetts Soil Suitability Assessment or On-site Sewa a Dis osal Performed By: t (j-AwN CAFE F0.0-IN Gt�� .trAc;> Date: 6 - ty.-9 . _. .... Witnessed By: ....................... .... t-eT Ioj LC� ZZ�SG o�r.w.nr. �jpnlA�l� G.4AI�C u-E?T1 . Lcnuon Address or i 1 G �,�a��. or AS&,^n-e � V%A PcL ty Address.and iZa TcicpAorc 5 f}oo1' rL e%1V(1 I41x.L. 1LOA•b LIX--9T 3^L,-j %Lg /O' �F�T 3AVtt4 rA4aL-E , N�A- o Z.bG6 oZ6"3z ew Construction Repair ❑ Office Review Published Soil Survey Available: No ElYes 1:2S�pock Soil Ma Unit U 1< �'... .. Year Published ................... Publication Scale P Drainage Class Soil Limitations Surficial Geologic Report Available: No ❑ Yes ❑ Year Published Publication Scale Unit ..... Geologic Material (Map.Unit) ..................................................................... .......................... Landform .......... Flood Insurance Rate Map: Above 500 year flood boundary No El Yes Within 500 year flood boundary No ❑Yes ❑ Within 100 year flood boundary No ❑Yes ❑ Wetland Area: National Wetland Inventory Map (map unit) .......... Wetlands Conservancy Program Map (map unit ......................................................................... ............. .. Current Water Resource Conditions(USGS): Month Range :Above Normal ❑Normal OBelc v Normal ❑ Other References Reviewed: DEP APPROVED FORM-12/07l95 t FOWNI II - SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot 0o. Lerr (`k LLF 2'L5S6 On-site Review Deep Hole Number _Tv 1 Date:. .6:�� L Time: W-00 AM Weather 75 F; 'ov4..- Location (identity on site plan) SCEcE.Tc H - - Land Use WooUED. : 0rcgr4T Slope M Surface Stones NoN Vegetation Won-s Landform MofV LAr\W&/ 0vyw"fsli Position on landscape (sketch on the back) Distances from: Open Water Body feet Drainage way feet Possible Wet Area feet Property Line '5L' feet Drinking Water Well feet Other DEEP OBSERVATION HOLE LOG' C\LJa:T(dv% C,-t-%P Vlak" = 41.5 \\\ 00At, Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface (Inches) (USDA) (Munsell) Mottling (Structure,Stones,Boulders,Consistency, % Gravel) o - 1 C7 Oleo- — C. A L S )o YR-3/-t — 1'LO G CQC 2.>L� 3 IO% Y^TO 50". . c0106la5 No wAl'E'R- 'FovND ,IN'MiJNA,OF 2 HDLES REQUIRED AT EVERY Parent Material (geologic), n\ .- ►0 DepthtoBedrock: �• at-Oi� Depth to Groundwater: Standing WaterinlheHole: Nl�e} Weeping from Pit Face: Estimated Seasonal High Ground Water: DLP APPR0\T1)FOKNt.12/07/95 FOPM 11 - SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot too. L'T 1 0) Lc.p 225K6 On-site Review Deep Hole Number 7912 Date:. Time: (0.00 AM Weather Location (identify on site plant SC.E. SI-ETct-i. . . Land Use VAc.A--J 1 Slope M 5�/o Surface Stones Vegetation W001> ='tom Landform GLArc_*r�� N�O�`Tt�►G-/°"T`"� M Position on landscape (sketch on the back) , Distances from: Open Water Body feet Drainage way feet Possible Wet Area feet Property Line !v45 feet Drinking Water Well feet Other DEEP OBSERVATION HOLE eko-J = (,,2-8 a Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface (Inches) (USDA) (Munsell) Mottling (Structure,Stones,Boulders,Consistency, % Gravel) — O C>t•Swv%;L I0Y1t 3/1 1 — G A 1_S lo`tN'Nlh -- G -3 I-1 t- M*-&;„Q j D%(V`5/& �w�tfi 3y-120" G s� 2,5Yz'_/ I o% eve.\ j Sows.. L'Mo ra ' ram-JAND 3 No w•4�1Z 1 Parent Material(geologic) 3\ac.\0J DepthtoSedrock: V. e)e&p Depth to Groundwater: Standing Water in the Hole: Weeping from Pit Face: Estimated Seasonal High Ground Water: Dl_P APPRo%TD romt-12r07M I FORM 11 - SOIL LVALUATOR FORM Page 3 of 3 Location Address or Lot No. L-CST m uq? Determination for Seasonal Higtz Water Table Method Used: Depth observed standing in observation hole........... .. inches Depth weeping from side of observation hole ........ . inches Depth to soil mottles inches Ground water adjustment .................. feet Index Well Number ................. Reading Date .................. Index well level .... Adjustment factor ................... Adjusted ground water level . .. ..................... Death of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? Yr.S If not, what is the depth of naturally occurring pervious material? Certification I certify that on NoV "�S (date) I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. Signature ) "� Date G /< < DEP APPROVED FORM-12/07195 FOR111 12 - PERCOLATION TEST 1 Location Address or Lot No. lac- \C> uq� 'L2t5ro COMMONWEALTH OF MASSACHUSETTS , Massachusetts r� Percolation Test* Date: ►6 G Time:, . J D AM Observation Hole #1 T�� Depth of Perc -rw eF perC C 301 Start Pre-soak End Pre-soak Time at 12" Time at 9" Time at 6" - 'C (G, V^,.. Time (9"-6") Rate Min./Inch Z_ * Minimum of 1 percolation test must be performed in both the e primary area AND reserve area. Site Passed X Site Failed ❑ .............................................................................................. ................ Performed By: '7J1 n1 O,JRL/R ('Dow^I C* CNh1N6 tNG-> Witnessed By: EA 'ice,0 V+ Comments: DEP APPROVED FORM•12/07/9s C e f r • LoT 19 1 L L-P 22.5*C, f Lcl GSM 1 G'� I P It- Ss - 00 /VO 5LALF_