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0144 AUGUSTA NATIONAL DR - Health
144 Augusta National Drive, A v I ` u 9 fl I a n i 0 1 -. J'ful TOWN OF BARNSTABLE �f o 7 r Aa� i9 �/,� ♦.tJs� �// SEWAGE # ,LOCATION VILLAGE ASSESSOR'S MAP &LOT b'b 215TALLER'S NAME 8t PHONE NO. SEPTIC TANK CAPACITY LEACHNG FACILITY: (type) (size) (size) NO.OF BEDROOMS Al7 BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 fat of leaching facility) Edge of Wetland and Leaching Facility(1f any w [lands exist Feet within 300 fee oac ;n facility) Furnished . 14i y Q�g�a54-0. fln�wru�l d-t- F 3,5 Commonwealth of Massachusetts F W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments L 144 Augusta National Drive Property Address Gary&C.harmaine.Levesque Owner Owner's Name . information is (— required for everyk n S' a J�� MA 02637 May 6, 2009 page. City/Town State Zip Code Date of Inspection f. Inspection results must be submitted on this form. Inspection forms may not_be altered in any . way. Important:when A. General Information filling out forms on the computer, use only the tab 9. Inspector: key to move your cursor-do not Troy Williams use the return key. Name of Inspector Troy Williams Septic Inspections r� Company Name . 19 Hummel Drive Company Address South Dennis MA 02660 Cityrrown State Zip Code 1508) 385-1300 S1682, Telephone Number License Number B. Certification I certify that l have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection: The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am.a DEP approved system,inspector pursuant to Section�5.340-of Title 5(310 CMR 15.000). The sys t6 m: A ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Q 7c,' �. + � � D� co S r.n r May 6, 2009 r 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 is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the.approving authority. ' ****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. . 144 Augusta National Drive,Cummaquid•03/OB I `� Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 a Commonwealth of Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage Disposal System. Form-Not for Voluntary Assessments 144 Augusta National Drive - Property Address Gary & Charmaine Levesque Owner Owner's Name information is required for every g Cumma uid MA 02637 _Ma 6, 2009 _ page. Cityrrown State Zip Code Date of.inspection B. Certification (cont.) . Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 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: System meets minimum standards set by Mass DEP at the time of inspection only, This,inspection is not a guarantee or warranty on the future working conditions of leaching, pipes or components. . 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 ,re air as approved.by Y the Board of Health will pass. Answer yes, no or not determined (Y, N, ND) in the ❑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 orexfiltration 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 leakingr and if a Certificate of Compliance indicating that the tank is less than 20 years old is available.- ND Explain: N/A ❑ 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 ❑ obstruction is removed 144 Augusta National Drive,Cummaquid-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 d Commonwealth of Massachusetts Title 5 OfficialInspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 144 Augusta National Drive Property Address Gary & Charmaine Levesque Owner Owner's Name - — information is Cumma uid' MA 02637 Ma 6 2009 required for every ----q------- ---- == -- - —T ' page. Cityfrown State Zip Code Date of Inspection B. Certification (Cont.) B) System Conditionally Passes(cont.): ❑ distribution box is leveled.or replaced ND Explain: N/A 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 ❑ obstruction is removed ND Explain: N/A C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a.manner which will protect public health, 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 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, 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. 144 Augusta National Drive,Cummaquid•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15' . Commonwealth of.Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 144 Augusta National Drive Property Address -- Gary & Charmaine Levesque _ Owner Owner's Name information is Cumma uid _ MA 02637 May 6,2009 required for every q — _ - Y page. City/Town State Zip Code Date of Inspection . B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): El 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: N/A " This system passes if the well water analysis, performed at a DEP certified laboratory, for 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. 3. Other: : N/A D) System Failure Criteria'Applicable to All Systems: : You must indicate"Yes".or."No"to each.of the following for all inspections Yes No a ® Backup of sewage into facility or system.component due to overloaded or clogged SAS or cesspool ® Discharge or ponding of.effluenf to the.surface of the ground or surface waters Ei due to an.overloaded,or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded ❑ 0 '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 El ® . . . tributary to a surface water supply. 144 Augusta National Dnve,Cummaquid•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System e,Page 4 of 15 I Commonwealth of Massachusetts ro Title 5 Official Inspection -Form o Subsurface Sewage Disposal System.Form-Not for Voluntary Assessments 144 Augusta National Drive Property Address Gary& Charmaine Levesque Owner Owner's Name information is = Cummaquid for every y MA 02637 May 6, 2009, ' required page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy-is within a Zone 1 of a.public well. M 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 coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure Criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. . El ® 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: E) Large Systems:..To be considered a large system the system must serve a facility with a design flow of10,000 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. D. Yes No ❑ M the system is within 400 feet of a surface drinking water supply ® the system is within 200 feet of a tributary to surface drinking water supply the system is located in a nitrogen sensitive area (InterirTJ Wellhead Protection j Area.—.IWPA)or a mapped.Zone Il of a public water supply well If you have answered"yes"to any question in Section E the system is considered asignificant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a"significant threat under Section E or failed under Section D shall upgrade the - system in accordance with 310 CMR 15.3.04. The system owner should contact the appropriate regional office of the Department: 144 Augusta National'Drive,Cummaquid;03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System;Page 5 of 15 3 I Commonwealth of Massachusetts Title 5 Official Inspection For a Subsurface Sewage Disposal System Form Not for Voluntary Assessments M 144 Augusta National Drive Property Address Gary& Charmaine Levesque Owner Owner's Name information is Cumma uid MA 02637 May 6,_2009 required for every- q y page. Cityrrown State Zip Code Date of Inspection: C. Checklist Check if the following have been done.,You must indicate"yes"or"no"as to each:of the following: ; 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? Have large volumes of water been introduced to the system recently or as part of ❑ ® this inspection? Were as built plans of the system obtained and examined? (if they were not available note-as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up?, . ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding'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 El 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)] 144 Augusta National Drive,Cummaquid•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 144 Augusta National Drive Property Address Gary& Charmaine Levesque Owner Owners Name information is Cumma uid MA 02637 May 6, 2009 required for every q y page. Citylrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 3+ Number of bedrooms (actual): 3 garbage DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd Number of current residents: 3 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry.system inspected?. ® Yes ❑ No Seasonal uses ❑ Yes M No Water meter readings, if available last 2 ears usage d 08=82,000gals 9 ( Y 9 .(gP )) 07=131,000gals Sump pump? ❑ Yes ®. No Last date of occupancy: Occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: N/A N/A` Design flow(based on 310 CMR 15.203): Gallons per day(gpd)i Basis of design flow(seats/persons/sq.ft., etc.): N/A Grease trap present? ❑ .Yes ® No Industrial waste holding tank present? _ ❑ Yes ® No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® .No Water meter readings, if available: N/A Last date of occupancy/use:. N/A Date Other(describe): N/A 144 Augusta National Drive,Cummaquid•03108 Title 5 Official Inspection Form:Subsurface Sawaga Disposal System•Page 7 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface,Sewage Disposal System Form-Not for Voluntary Assessments 144 Augusta National Drive Property Address. Gary & Charmaine Levesque Owner Owner's Name information is Cmma uid MA 02637 May 6, 2009 u required for every 4 page. CityfFown State Zip Code Date of Inspection D. System Information .(cont.) General Information Pumping Records: Source of information. Last pumped in 2002 per home owner. Was system pumped as part of the inspection? ❑, Yes No If yes, volume pumped; N/A gallons , How was quantity pumped determined? N/A N/A Reason for pumping: Type of System: Septic tank, distribution box, soil absorption system El Single cesspool . El 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: Tank,d-box& leaching were installed on 8/23/79 per as-built. Were sewage odors detected when arriving at the site? ❑ Yes ® No ,144 Augusta National Drive,Cummaquid 03f08 Title 5 Official Inspection Form:Subsurface Sewage;Disposal System-Page 8 of 15 Commonwealth of•Massachusetts rZ Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 144 Augusta National Drive Property Address Gary &Char_maine Levesque Owner Owner's Name -- information fo is Cumma uid MA 02637 May 6, 2009 required for every q y page. Citylrown State Zip Code.. Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 18"+ feet Material of construction: ❑ ® sch 30 cast iron 40 PVC other(explain):`. Distance from private water supply well or suction line. N/A feet Comments(on condition of joints, venting,evidence of leakage, etc.): Flushed lines and found clear at the time of inspection. Septic Tank(locate on site plan): Depth below grader . 18" feet Material of construction: ® concrete ❑ metal ❑ fiberglass polyethylene other,(explain) If tank is metal, list.age: N/A years Is age confirmed by a Certificate of Compliance? (attach a copy of-certificate) ❑ Yes [] No • Dimensions: 6'X 10.5'X 6' 1500 gallon 61, Sludge depth: 2'6„ Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 6,. Distance from top of scum to top of outlet tee or baffle 6�,Distance from bottom of scum to bottom of outlet tee or baffle l 8' How were dimensions determined? Probe Measured 144 Augusta National Drive;Cummaquid•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of,15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 144 Augusta National Drive Property Address Gary & Charmaine Levesque Owner Owner's Name information is Cumma uid MA 02637 May 6, 2009 required for every q y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): . - Pvc inlet and outlet tee's were present. No evidence of leakage or damage:was found.Tank was in need ofpum ing at this time. Grease Trap(locate on site plan): Depth below grade:. N/A feet Material of construction: ❑ concrete F metal El fiberglass ❑ polyethylene :❑ other(explain): N/A N/A Dimensions:. Scum thickness 'N/A Distance from top of scum to top of outlet tee or.baffle N/A Distance from bottom of scum.to bottom of outlet tee or baffle N/,A Date of last pumping: N/A 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.):` N/A Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/A Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene []'Other(explain)'. N/A 144 Augusta National Drive,Cummaquid•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 144 Augusta National Drive Property Address Gary & Charmaine Levesque Owner Owner's Name information is Cummaquid MA 02637 -May.6, 2009 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: N/A Capacity: N/A gallons . N/A Design Flow: gallons per day Alarm present: ❑, Yes• E No Alarm level: N/A Alarm in working order`. El Yes El No Date of last pumping. N/A Date Comments.(condition of alarm"and float switches, etc.): Attach copy of current pumping contract,(required).Is copy,attached? 0 Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Level with 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.):, t.. D-box was found level and in working order with outlet to pit#2,slightly lower than outlet to pit#1. 'Pump Chamber(locate on site plan): Pumps in working order: [:1 Yes 0 No Alarms in working order: 7 ❑..Yes E No 144 Augusta National Drive,Cummaquid•03/08 Title.5 Official Inspection Form:Subsurface Sewage Disposa! ystem:Page 11 of 15 " Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 144 Augusta National Drive Property Address Gary& Charmaine Levesque Owner Owner's Name information is required for every Cumma uid MA 02637 May 6;2009 page. . cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): N/A Soil'Absorption System (SAS) (locate on site plan,excavation not required):. If SAS not located, explain why: N/A Type 2-5.5' - ® leaching pits _ number: w/2'stx6'pitone 0 leaching chambers number. leaching galleries number.. ❑ leaching trenches number, length: El leaching fields number, dimensions: ' 0 overflow cesspool number:; 0 innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation; etc.) Soil was sandy.Leach pit#1 was found with 7"of water present with walls found clean above water level. No evidence of hydraulic failure or problems in the past were.found in pit#1'at the time of inspection. Pit#2 has no available capacity at this time. 144 Augusta National Drive,Cummaquid•03/08 Title 5 Official Inspection form:Subsurface Sewage Disposal System Page 12 of 15 f Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 144 Augusta National Drive Property Address Gary& Charmaine Levesque Owner Owner's Name information is Cumma uid MA 02631 May 6, 2009 required for every q y page. Citylrown State Zip Code Date of Inspection D. System Information(cont.) Cesspools (cesspool must be.pumped as part.of inspection) (locate on site plan): Number and configuration N/A Depth—top of,liquid to.inlet invert N/A Depth of solids layer N/A Depth of scum layer N/A Dimensions of.cesspool N/A Materials of construction N/A Indication of groundwater inflow Yes ® No Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): . N/A Privy(locate on site plan): :x Materials of construction: N/A Dimensions N/A'. Depth of solids N/A Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, . etc.): 144 Augusta National Drive,Cummaquid•03/08 _ -- - _ .`-Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 144 Augusta National Drive Property Address Gary& Charmaine Levesque Owner Owner's Name information is Cumma uid - MA 02637 May.6, 2009 required for every 4 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont). Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where.public water supply,enters the building. 3 3 33 v . _ p 144 Augusta National Drive,Cummaquid•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 144 Augusta National Drive Property Address Gary & Charmaine Levesque Owner Owner's Name _ information is id MA 02637 M Cumma ua 6, 2009 required for every q - Y page. Cityrrown State Zip Code Date.of Inspection D. System.Information (cont.) Site Exam: ® .Check Slope `® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 18'+ feet, Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record 4/11/79 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 docu mentation) Accessed USGS database explain: AIW 247 Zone B 22.9 2.2 adjustment 1 You must describe'how you established the high ground water elevation: Soil was silty sand &clay. Hand augered 4' below bottom of leaching with no water found at 13.2'. Groundwater adjustment in area at the time of inspection was 2.2'. Bottom of leaching at 9.2'was found not to be located in the.high groundwater elevation at the time of inspection Elevations on plan ; show water level to be approx.24' below grade: 144.Augusta National Drive.Cummaquid•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15.of 15 DATE:LLO—'------ PROPERTY ADDRESS; 1.44 Augusta National Drive __Sta�uid------------- Mass. ----------------- On the above date, I Inspected the septic ,aystem at the above address. This system conslsts of the following; 1 . 1 -1500 gallon septic tank. 2. 1 -Distribution box. 3. 2-1000 gallon precast leaching pits. Based on my Inspection, I certify the following condltlonv, 4 . This is a title five septic system. ( 78 Code :5 . The septic system is in proper working order t ---mat the .present time. 6 . #1 pit Waste water is 39 ' below invert #2 pit is dry. SIGNATURE:,, Name :-,La Apssmktr--4L ------ Company; 1oai�h_P _ Necomb�r_b Son , Inc , Address ;_ Box_66----- -------- __Centerville Na_-02692-0066 Phone:__ 50 ------- - THIS CERTIFICATION DOGS NOT CONSTITUTH A OUARANT'Y OR WARRANTY JOSEPH P. MACOMBER & SON, INC, T+nks•Ce$$pools•LsachfIoIds PUmp#d 4 Instsllod Town Sewer Conneotlons P.O. Box 6y75,JJ38 �e77. 102632-0066 RECEIVED FEB 0 .9 Z001 TOWN BLE HEALTH DEPT. -\ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION i TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION ' Property Address: 144 Augusta National Drive ummaqui ,Mass. Owner's Name: Stephanie Hartwig Owner's Address: Same Date of Inspection: 2/8/01 Name of Inspector: (please print) Joseph P.Macomber Jr Company Name: J.P.Macomber & Son Inc. Mailing Address: Box 66 Centerville,Mass. 02632 Telephone Number: 50 8—7 7 5—33-48 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true.accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: �c�Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: '��� The system inspector shall s mit a copy of this inspection r ort to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner.shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 • t° "�. Paae 2 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 144 Augusta National Drive ummaqui , ass. Owner: Stephanie Hartwig Date of Inspection: 278/01 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D: A. System Passe al D 1 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: A)n.Ar� 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. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If"not determined"please explain. _ Q 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. ND explain: _ 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 obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced ; obstruction is removed ND'explain: 2 Page 3 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 144 Augusta National Drive ummaqui ,Mass. Owner:Stephanies Hartwig Date of Inspection: 2 8 01 C. Further Evaluation is Required by the Board of Health: etj 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. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health,safety and the environment: A16 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 any)determines that the system is functioning in a manner that protects the public health,safety and environment: A& 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 I of a public water supply. �Q 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 supple well". Method used to determine distance Ul "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 144 Augusta National Drive Cummaguid,Mass. Owner: Stephanie Hartwig Date of Inspection: 2/8/01 D. 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 faciliry'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 Static liquid level in.the distri,�ution box above outlet invert due to an overloaded or clogged SAS or cesspool • f��'S _ �i quid de thin is less than 6"below invert or available volu I than ' day w q p soss�ee�l me is less h n h y flow equired pumping more than 4 times in the last year NOT due to clogged or obstructed.pipe(s). Number ° of times pumped ny 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 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 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, provided that no other failure criteria- are triggered. A copy of the analysis must be attached to this form.] /!)l1 (Yes/No)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 0. Health to determine what will be necessary to correct the failure. E. 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• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no - _ Zthe system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply _ //the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of I I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 144 Augusta National Drive Cummaquid,Mass. Owner: Stephanie Hartwig Date of Inspection: 2/8/01 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes N - 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 N/A) I/ 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, luding 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: Yes no Existing information. For example, a plan at the Board of Health. z 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(3)(b)J 5 Page 6 of 1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1 1 4 Augusta National Drive Cummaguid,Mass. Owner: Stephanie Hartwig Date of Inspection: 2/8/01 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): Number of current residents:_q Does.residence have a garbage grinder(yes or no):tVV Is laundry on a separate sewage system (yes or no): u i [if yes separate inspection required) Laundry system inspected(yes or no): ' C Seasonal use: (yes or no): &jO Water meter readings, if available(last 2 years usage Sump pump(yes or no): Last date of occupancy: COMM ERCIALMIDUSTRIAL Type of establishment: iJ/19 Design flow(based on 310 CMR 15.203): .ghi gpd Basis of design flow(seats/persons/sgft,etc.): y,Q Grease trap present(yes or no): V Industrial waste holding tank present(yes or no): / Non-sanitary waste discharged to the Title 5 system (yes or no):. i Water meter readings, if available: Last date of occupancy/use: 414 OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): If yes, volume pumped: 40 gallons -- How was quantity pumped determined? dig Reason for pumping: TYPE OF SYSTEM Septic tank, distribution box, soil absorption system Single cesspool Overflow cesspool 1 Privy Nv 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) i✓�Tight tank N/4 Attach a copy of the DEP approval NG Other(describe): AAe� Approximate age of all c m nents,date installed(if known)and source of information: 6 - Were sewage odors detected when arriving at the site(yes or no):mil 6 Page 7 of 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 144 Augusta National Drive Cummaguid,Mass. Owner: Stephanie Hartwig Date of Inspection: 2/8/01 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: ezcast iron A*'140 PVC e6 other(explain): A14 Distance from private water supply well or suction line: .0 Comments(on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK: JZ(locate on site plan), Depth below grade: Material of construction:, concrete A,16 metal Eafiberglass polyethylene �Cather(explain) � If tank is metal list age: 4M Is age confirmed by a Certificate of Compliance(yes or,no): (attach a copy of certificate) " Dimensions: b r! `�J170 Sludge depth: 'j Distance from top of>s ydge to bottom of outlet tee or baffle: . Scum thickness: --. Distance from top of scum to top of outlet tee or baffle: Distance from bonom of scum to bottom of outlet tee or baffle: How were dimensions determined: _ Comments(on pumping recommendations, inlet and outlet tee or baffle condition._structural integrity, liquid levels. as related to'outlet invert,evidence of leakage, etc.): Pump septic tank every 2-3 years-Inletl- outlet tees are in place The tank is structurally soLnc3 anf3 shnws no evidence of leakage. GREASE TRAPrs�&(locate on site plan) Depth below grade: .tJl!' Material of construction:,t/X concrete metal eafiberglass,t/�4Polyethylene other (explain): Dimensions: /Lk Scum thickness_ 1_4 9i _ Distance from top of scum to top of outlet tee or baffle: Z/100 . Distance from bottom of scum to bottom of outlet tee or baffle:�� s Date of last pumping: 14 Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease trap is not present f ' p 7 Page 8 of 1 I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 144 Augusta National Drive Cummaquid,Mass. Owner:Ste hani rtwict- Date of Inspection: TIGHT or HOLDING TANK:Ab.Vt(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: A0 Material of construction: d[Z_concrete iMmetalAl,,2_fiberglass&d polyethylene&121_other(explain): Dimensions: .yA Capacity: gallons Desien Flow: AM _gallons/day Alarm present(yes or no): .41,4 Alarm level: Alh Alarm in working order(yes or no):�/ Date of last pumping: AM Comments (condition of alarm and float switches,etc.): Tight or holding tanks are not present DISTRIBUTION BOX: Z(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: A10 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.): i i .c; hi1f hnx ha-- t-Wn 1 ^4-er^1c No Qyid.en68 of selids carry/ nvpr Nn avi dPnnP nf 1 eakarrc.—into or out cf thehex S PUMP CHAMBERW,&& (locate on site plan) Pumps in working order(yes`or no): Alarms in working order(yes or no): Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Pump chamber is not present 8 y Page 9 of I I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued). Property Address: 144 Augusta National Drive Cummaguid,Mass. Owner: Stephanie Hartwig. Date of inspection: 2/8/01 SOIL ABSORPTION SYSTEM (SAS):. (locate on site plan,excavation not required) If SAS not located explain why: i Located Type eaching pits,number: v4 Al leaching chambers,number:6 NU leaching galleries,number: 6 2_�2 leaching trenches,number, length: Q A16 leaching fields,number,dimensions: 4 A)Q overflow cesspool,number: 0 �2 innovative/altemative system Type/name of technology: Ti t 1 P Pi the 78 code Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): Loamy sand to clay to fine coarGP sand Nn signs of hydraLllic failure or ponding CESSPOOLS:a11g_(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: O Depth—top of liquid to inlet invert: 1f)I Depth of solids layer: >�4 Depth of scum laver: ,I/A Dimensions of cesspool: 41A Materials of construction: 41)4 Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Cesspools are not present PRIVY:n/�(locate on site plan) Materials of construction: AJiF Dimensions: ,,/A Depth of solids: ,4,1,4 Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): Privy is not present 9 Page 10 of I 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 144 Augusta National Drive Cummaauid,Mass. Owner: Stephanie Hartwig Date of Inspection: 2/R n 1 SKETCH OF SEWAGE DISPOSAL'SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. I 2-- \ -Z- / \ 4 \ OFF U / // b 10 Page I I of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 144 Augusta National Drive Cummaquid,Mass. Owner:Stephanie Hartwig Date of Inspection: 2/8/01 SITE EXAM Slope - Surface water Check cellar Shallow wells Estimated depth to ground water �J� feet Please indicate (check)all methods used to determine the high ground water elevation: l Ob[ em desi plans on record - If checked, date of design plan reviewed: RJR bserved site(abutting prope bservation hole within 150 feet of SAS) Checked wit oca oar o Health-explain: _ Checked with local excavators, installers- (attach documentation) _ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Used water contours Map Gahrety & Miller Model 12/16/94 11 " ',r•rnT+•—n1'I^TT�Rrn-RR nTR TnIT STrr,fTR .'T'�'nR►rinrfRnT TRT+{1Y TA'�JT.pInT TTTTr-4�—. - -- ., 'FOHN OF Barnstable WARD OF IIEALTII SlJ(fSU1tFACR 9FHAGE DISPOSAL SYSTEM IN�9i'FCTI08 FORM - PART D^- CERTIFICATION r _ -TYPL OR PRINT C1.EARL1•- PI?OPERTY INSPECTED STREET ADDRESS 144 Augusta National Drive Cummaguid,MASS. ASSESSORS MAP, DLOCK AND PARCEL # OWNER' s NAME Stephanie Hartwig PART D - CERTIFICATION Y NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & Son Inc.'' R COMPANY ADDRESS Box 66 Centerville,Mass. 02632 Street Town or City State LIP COMPANY TELEPIiONE ( 508 1 775 - 3338 FAX ( 508 ) 790 - 1578 q CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at ®rlecoininendations his address and that the information reported is true , accurate , and omplete as of the time of .inspection . The inspection was performed and any regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems , Check one : !Syste ' PASSED The inspection which I have conducted has .not found any information which indicates that the system fails to adequately protect public health or Lhe environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this florin. System FAILED* The inspection which I have con lcted has found that the system fails to Protect the j-)ublic health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE -CRITERIA of this inspection form , Inspector Signature G Date —�d ecopy of this ce tification must be provided to the OWNER, the BUYER On where applicable ) and the 130ARD OF HHAL1'll. It the inspection FAILED, the owner or "� orator ahall u " 'P pgrado ' tho eyetem within one year of the date of the inspection, unless allowed or required otherwise as provided in 310 CMR 15 . 305 . partd . doc Commonwerari of Massachusetts ExecutNe Office of ErMrorymintai Affairs John Gf•aci D.E.P. Title V Septic Inspec(or Department of P.O. Boy 2119 Environmental Protection Teaticket, A1F102536 (508) 564-6813 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 144 Agusta National Dr. Cummaquid Address of Owner: Date of Inspection:1113197 (If different) Name of Inspector:John Gracl Edna Tillman:135 Wheeler Rd.Marslons mills Company Name,Address and Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: X Passes This inspection is based on criteria defined in Title V Conditionally Passes code 310 CMR 15.303.My findings are of how the system is _ Needs F e Evaluation By the Local Approving Authority performing atthe time of the Inspection.My Inspection does Fails not Imply any warranty or guarantee of the longevity of the septic system and any of its components useful life. Inspector's Signature: Date: m3197 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. 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 p 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: A] SYSTEM PASSES: X I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: _One or more system components need to be replaced or repaired. The system, upon 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 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. (revised 11115195) One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 144 Agusta National Dr.Cummaquid Owner: Edna Tillman:135 Wheeler Rd.Marstons Mills Date of Inspection:1113197 Sewage backup or breakout or high static water level observed in the distribution box is 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 leveled 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: 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 of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 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 volatile organic compounds indicates that the well is free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm. 3) OTHER D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage in 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 cesspool. SAS is in hydraulic failure. (revised 11115195) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 144 Agusta National Dr.Cummaquld Owner: Edna Tillman:135 Wheeler Rd.Marstons Mills Date of Inspection:1113197 D) SYSTEM FAILS(continued) 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). Numbers of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply wets with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach Y P copy of well water analysis for Y coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. EJ LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria: 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 the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area (IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 11115/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 144 Agusta Natlonat Dr.Cummaquld Owner: Edna Tillman:135 Wheeler Rd.Marstons Mills Date of Inspection:1113197 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 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. n1a 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 septic tank was inspected for condition of baffles or tees,material of construction,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 determined based on existing information or approximated by non-intrusive methods. X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11115195) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 144 Agusta National Dr.Cummaquid Owner: Edna Tillman:135 Wheeler Rd.Marstons Mills Date of Inspection:1113197 FLOW CONDITIONS RESIDENTIAL: Design flow: 449 gallons Number of bedrooms: 4 Number of current residents: 9 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings, if available: Ma Last date of occupancy: 4 months ago COMMERCIAL/INDUSTRIAL: Type of establishment: We Design flow:9 gallons/day Grease trap present:(yes or no) No Industrial Waste Holding Tank present: (yes or no) No Non-sanitary waste discharged to the Title 5 system:(yes or no) No Water meter readings,if available: n/a Last date of occupancy: n1a OTHER: (Describe) n►a Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System has never been pumped System pumped as part of inspection: (yes or no)No If yes,volume pumped: 9 gallons Reason for pumping: nla TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions 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 information: 1979 Sewage odors detected when arriving at the site:(yes or no) No (revised 11115/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 144 Agusta Natfonai Dr.Cummaquid Owner: Edna Tolman:135 Wheeler Rd.Marstons Mills Date of Inspection:1113/97 SEPTIC TANK: X (locate on site plan) Depth below grade: T Material of construction:X concreate_metal_FRP_other(explain) Dimensions: L 8'li'H 5'7"W 4'10' Sludge depth:5' Distance from top of sludge to bottom of outlet tee or baffle: 22" Scum thickness:0 Distance from top of scum to top of outlet tee or baffle:12" Distance form bottom of scum to bottom of outlet tee or baffle: 12• 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.) Septic tank and all components are structurally sound.Recommend pumping system every year for maintenance. GREASE TRAP: (locate on site plan) Depth below grade: n/a Material of construction: _concrete_metal_FRP_other(explain) Dimensions: n1a Scum thickness:n1a Distance from top of scum to top of outlet tee or baffle:n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a 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.) n1a (revised 11/15195) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 144 Agusta Natlonal Dr.Cummaquld Owner: Edna Tillman:135 Wheeler Rd.Marstons Mills Date of Inspection:1113197 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: n1a Material of con struction:_concrete_metal_FRP_other(explain) Dimensions: Wa Capacity: n1a gallons Design flow: n1a gallons/day Alarm level: n1a Comments: (condition of inlet tee,condition of alarm and float switches, etc.) n1a DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert: Liquid level with bottom of pipe. Comments: (note if level and distribution is equal,evidence of solids carryover, evidence of leakage into or out of box etc.) Distribution box is structurally sound. PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) n1a (revised 11115195) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 144 Agusta National Dr.Cummaquid Owner: Edna Tillman:135 Wheeler Rd.Marstons Mills Date of Inspection:1113197 SOIL ABSORPTION SYSTEM(SAS):X (locate on site plan,if possible; excavation not required,but may be approximated by non-intrusive methods) If not determined to be present, explain: nla Type: leaching pits,number: 2-1,000 gallon leach pits leaching chambers,number:nfa leaching galleries,number: nfa leaching trenches,number,length: nla leaching fields,number, dimensions:nfa overflow cesspool,number:nla Comments:(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.) The sas is functioning properly and Is sturcturally sound. CESSPOOLS:_ (locate on site plan) Number and configuration: nfa Depth-top of liquid to inlet invert: nfa Depth of solids layer: nfa Depth of scum layer: nfa Dimensions of cesspool: nfa Materials of construction: nla Indication of groundwater: nfa inflow(cesspool must be pumped as part of inspection) nla Comments:(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) nla PRIVY:_ (locate on site plan) Materials of construction: nfa Dimensions: nfa Depth of solids: nfa Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) nla (revised 11/15195) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 144 Agusta National Dr.Cummaquid Owner: Edna Tillman:135 Wheeler Rd.MarsionsMllls Date of Inspection:1113197 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' �p A t Rc3q Gc 34 �E31 DEPTH TO GROUNDWATER Depth to groundwater:12 feet method of determination or approximation: USGS Maps and Charts (revised 11115195) 9 LOCATION SEWAGE PERMIT NO. � � G VILLAGE dJ� '49721-,/& SOARS Sow We..- - 4004aljIf STA LLER'S NAME i ADDRESS BUILDER OR OWNER DATE PERMIT ISSUED - /®,S_ 7;f, DATE COMPLIANCE ISSUED_ ` �5` yovSE i; �,�. �" . V-s a s S� .�t,�' t9' r tip �i No........................ Fia ...... ... ... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN.............•---....OF............. BARNS TABLE.............. Appliration for Uhgpos al Works Tonstrurtinn Frrutit Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Pisposal -- System at: ........A,tlgu.SA .a..�1,z.tianal..IIxive LQL._. 12�..._" , ------•......... ..... Location-Address or Lot No. ........Halt ar--&...zi.ta..8 e=.................................... --------Cumber-3.and.,....R.-I............................................... Owner Address WA. S_ears & SQn".... I.IC..-•-------•-•................................... ......... .-...................................................... Installer Address d Type of Building Size Lot...37,500........Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder (X ) 04 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures .................................. ........ oom Design Flow...........110 r .........................gallons per r`l'per day. Total daily flow.......330_____.__...................._gallons. � Septic Tank—Liquid capacityl5 0 0_gallons Length_10..6''.. Width.5!10_"_ Diameter................ Depth 5 4" Disposal Trench—No..................... Width..._......._._...__. Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..... ............. Diameter-10.....t. . Depth below inlet_..6---ft.--- Total leaching area....534 sq. ft. Z Other Distribution box ( X) Dosing tank ( ) '-' Percolation Test Results Performed by......R. King .. Date....4/11/79 Test Pit No. I---_......2.---minutes per inch Depth of Test Pit 14 4" Depth to ground water........................ Test Pit No. 2_...._..._2...minutes per inch Depth of Test Pit.l4 4" _ Depth to ground water........................ -------------------------------------------------------•---•--------------..........--•-•----.•---••......................................................... 0 Description of Soil....0.l - 0-4" Woodloam`__4"_-66...._ClaX subsoil 66"-144" Clean .......... .... ...........•-• ......... ------. ....----•.--. :----....... W medium to coarse sand, #2- 0-4" Woodloam, 4"-54" Clav subsoil_, v 54' 144" Clean meduum sand & stone 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 Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bD= issued by the oard of healt 79 Signed d� .................. •-• ---- •----•--------- .._!_g�° `.�/9 Date ApplicationApproved By............TiA .....-•----------------•--------------•--•----------.............•••_...• ..............4 ...... ... Date Application Disapproved for the following reasons:................................................ --------------•---------•••••---------•••-----••--•---•--•---.....---•-----••-...-•-••-••--•----•-•-••-•--•----••---•••-------•--••------•-•----...••------••-•---•-••--•--•••••--••------••.....••-•--- Date Permit No............. y�_._....-----------.------...._ Issued_,---- -`2S- 7 ---_..._ Date 410- No..... !,...... FEB....,pe?. .....fir.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...---_.TOWN......-.-.-- .---0 F...-...:...:BARN ''�1BE.:......:..:. firatilan f orX Dispos al Works Tonstrnrttnn ermit Q Application is hereby made,for a Permit to Construct (X") or Repair ( ) an Individual Sewage Disposal System at ............................ ........ ........_..----•-•---------•-------................................. ` Location-Address. or Lot No. Alto:__4...;Ita...mexia..................................... ........C er anda....R._A...........------...._. Owner Address W "f A. Sears & Son, Inc. Dennis, -•-•-•-••••-•..... ••..... ... .............•-------•--•---...................._..__. Installer Address d Type of Building Size Lot__ilt.KQ=______-_Sq. feet ►-a Dwelling—No. of Bedrooms..........3................................Expansion Attic ( ) Garbage Grinder (x ) Other-Type of Building ............................ No. of persons____________________________ Showers — Cafeteria Otherfixtures $ --------------•-----•............................................. W Design Flow.................................................................gallons per �pr day. Total dailyflow___._.330--_____________________--, dons. WSeptic Tank—Liquid capacityt_50P-_gallons Length lo-�6��__ Width5.f_1: �._. Diameter................ Depth5. 411 x Disposal Trench—.No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No --- Diameter.l.. ft. Depth below inlet..6__...t'.... Total leaching area............ sq. ft. Z Other Distribution box ( X) Dosing tank `-' Percolation Test Results Performed by R. King tj D 4/11/79 ate_:_ Test Pit No. I_________ ____minutes per inch Depth of Test Pit 14 _.f_.._.__. Depth to ground water........................ 4 Test Pit No. 2..........2....minutes per inch Depth of Test Pit_144 Depth to ground water________________________ R' a n_ �1 ti_ 7r D Descri n of Soil___#�.__-..0-4 Woddloam, 4 66 Clay subsoil-„hb ____4 Clean-__---- to coarse sand, # -___0_4" Wooc� oam, 4" 5n___CYay sulisoi ------------------- medium , . W r_.__ ...ff_... ----•-. ---- _ 5�_.__ �44 Clean mec�uim sand-•&••stone:••---- .. 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 TLITI.,Z 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance ha issued b the bard of health. Signed) Date Application Approved By.........._ � �. �_�,5""-._:'__!___ Date Application Disapproved for t e f ollowing reasons:----••-------------------------------------------------•---•---•---------------•---------------•-••--......_..._ .................................•----------•------••--------•------------------•----------------...._.....--------------------------------•-----••----------------------...-----••••••••--•-•---•---•--- Date Permit No............ ...... Issued_ ..... Date THE'COMMONWEALTH OF MASSACHUSETTS 3 , ARD OF HEALTH o . ................. ........................... :F •t (9rdifirFate of Tuntpli atta THIS IS TO CERTIFY,That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by................ ......., spa S t...._....... Installer , at �l -.•--•-f -�---•-•-----, Jv ti�rT,r/s� j4./i' �G!r�i� +�111C •--••----- --••--•. .......................................................... has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the- application for Disposal Wor'ks,�Coristruction Permit o '- �" 4:�__________________ -- ' k. ¢�_; �, Y dated------ .1 .'. -----• THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONST UE® AS GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. c DATE... .. .. Inspector •-• - .................................................., , kv �'X '�Pt= :�7 THE COMMONWEALTH OF MASSACHUSETTSt f' BOARD AF4,hfiE4LTH G' ..OF...., No........ _ C'U ,i r�h.. _. FEE........ai ......... Dispos al 1vorkli Tonstrnrtuan rani# Permission is hereby granted.......""..........l.......... ---•-----------------------------•-------------------•-•------•-----...._.__..._.:.------•--- to Construct (X or Repair ( ) an Individual Sewage Disposal System Street as shown on the application for Dis saF`Works Construe'onAFeiiru TVo.__„ '��f_______ Dated___ '... GG JL,/ 7 ..... DATE................... i .....---- Boa Health rd of H 3 z+ FORM d25S HOBBY:,& WARREN. INC:,-PUBLISFIERS�" °. lr '..� tit 41'• �• '` � ,41y F a '-p ,asNveA,r'iy�..4r+ vp•�wfr++.wta.....a.yni.,i�ro.,pwsert.r+.nn�w.r�.'ssawr..da'•.wemM Ma.,.awwswana..•,+v+a ._iisrwn^"f�'s u i"4a:' x,�� �trwwy ?^b 3x 'i � ,z. 0ti*�'`'.} tr r •cG' x !b _�Wd.w.'�. Y yp� kua + r �' r x'' x h 9i A.'Y•+s.P �'r ,tif. 4':t� '" f' t N-ix,S"'% 03# 4 � 1 J••'Y r �'f� u .. t al a m: > v v r �,- t N F ✓N ia `T i? `.4ur (�':."`' {j 1� T 'ri rr ". 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