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HomeMy WebLinkAbout0010 BLACK DUCK LANE - Health 10'BIack Duck Lane Barnstable P A = 237 009001 J` Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 Black Duck Lane- 'st Barnstable, MA Property Address Martin Kennedy -6 Volunteer,Road Owner Owner's Name information is required for East Sandwich MA 02537 11/1.2/2007 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. Important: A. General Information When-, hen flling out forms on the computer,use 1, Inspector: only the tab key to move your Robert J. Bortolotti cursor-do not Name of Inspector use the return , - o c) l C - 0 key. Bortolotti Construction, Inc. lJ Company Name 45 Industry Road - P. O. Box 704 Company Address Marstons Mills MA 02648 City/Town State Zip Code 508-771-9399 Telephone Number License Number B. Certification 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 maintenanceof 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: Passes ❑ Conditionally Passes ❑ Fans > ❑ Needs Further Evaluation by the Local Approving Authority a t�, ! ector'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 copiessent 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. t5insp-08/06. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 10.Biack Duck Lane West Barnstable, MA Property Address Martin Kennedy-6 Volunteer Road Owner Owner's Name information is required for East Sandwich MA 02537 11/12/2007 . every page. City/Town _ 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: [ 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: 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 approve&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: ❑ 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 ofsewage backup or breakout 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 t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 Black Duck Lane-West Barnstable, MA Property Address Martin Kennedy-6 Volunteer Road Owner Owner's Name information is required for East Sandwich MA 02537 11/12/2007 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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: 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 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: ❑ 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. t5insp•08/06 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 �M 10 Black Duck Lane-West Barnstable, MA Property Address - Martin Kennedy-6 Volunteer Road Owner Owner's Name information is required for East Sandwich MA 02537 11/12/2007 every page. City/Town State Zip Code Date of Inspection B. Certification (c(int.) C) Further Evaluation is Required by the.Board of Health (cont.): ❑ 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 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: 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 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 ElStatic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ElLiquid depth in cesspool is less than 6" below invert or available volume is less than V day flow 0 ElRequired 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. t5insp•o8/66 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 r Commonwealth of Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 Black Duck Lane-West Barnstable, MA Property Address Martin Kennedy-6 Volunteer Road Owner Owner's Name information is required for East Sandwich MA 02537 11/12/2007 every page. City/Town 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. ❑ ❑ 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. ❑ ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303i the 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 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 D. 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 supplyEl . ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection 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 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. t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts v W Title. 5 Official Inspection Form Subsurface Sewage Disposal System Form =Not for Voluntary Assessments . 10 Black Duck Lane-West Barnstable,MA Property Address Martin Kennedy-6 Volunteer Road Owner Owner's Name information is required for East Sandwich MA 02537 11/12/2007 . every 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 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•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 1.5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10 Black Duck Lane-West Barnstable, MA Property Address Martin Kennedy-6 Volunteer Road Owner Owners Name information is required for East Sandwich MA 02537 11/12/2007 every page. City/Town State Zip Code Date of Inspection D. System Information 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 Number of current residents: vacant Does residence have a garbage grinder? 0 Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No - Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd))- 05 =Iql o"" Sump pump? ❑ Yes ® No Last date of occupancy: Been vacant for two years Commercial/Industrial 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 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): t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts v. Title 5 Official . Inspection' Form s Subsurface Sewage Disposal System Form Not for Voluntary Assessments 10 Black Duck Lane-West Barnstable, MA, Property Address Martin Kennedy-6 Volunteer Road Owner. Owner's Name information is required for East Sandwich MA 02537 11/12/2007 every page. City/Town State Zip Code Date of.Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Pumped 2/05-furnished by owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: 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) El Innovative/Alternative technology. Attach a copy of.the current operation and maintenance contract(to be obtained from system owner). ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Twenty years old. Were sewage odors detected when arriving at the site? ❑ Yes ® No. t5insp•08/06 Title 5 Official Inspection Form:.Subsurface Sewage Disposal System•Page 8 of 15 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4M , 10 Black Duck Lane-West Barnstable, MA - -- - Property Address Martin Kennedy-6 Volunteer Road Owner Owner's Name information is required for East Sandwich MA 02537 11/12/2007 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on,site plan): Depth below grade: 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.): Septic Tank(locate on site plan): Depth below grade: Inlet 6" Outlet 48"to grade feet .. Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: `, . . years Is age confirmed by Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 8.5'x 6'.x 5' Dimensions: none Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle Scum thickness none' Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? physical observation t5insp•06/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form Not for Voluntary Assessments 10 Black Duck Lane-West Barnstable, MA Property Address Martin Kennedy-6 Volunteer Road Owner Owner's Name information is required for East.Sandwich MA 02537 11/12/2007 . every page. City/Town 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.): It's a 1000 gallon H-10 precast septic tank with inlet cover 6"to grade and outlet cover 48"to grade, it has cement inlet and outlet tes with no scum or sludge at time of inspection-water level in tank'is low due,to being Vacant for two years. 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.):. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site.plan): Depth below grade: Material of construction: El concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): t5insp•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page.10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10 Black Duck Lane-West Barnstable, MA Property Address Martin Kennedy-6 Volunteer Road Owner Owner's Name information is required for East Sandwich MA 02537 11/12/2007 every page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day 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 Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Working level Comments`(note if box is level and distribution to outlets egtaal,"any,evid'ence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution Box is 54" to grade and at working level at time of inspection. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No " Alarms in working order: ❑ Yes ❑ No 15insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 15 Commonwealth of Massachusetts Title. 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �.y 10 Black Duck Lane-West Barnstable, MA Property Address Martin Kennedy-6 Volunteer Road Owner Owner's Name information is East Sandwich MA 02537 .11/12/2007 "required for every page. Cityrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): 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: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): It's a 1000 gallon H-10 precast leach pit with covers 18" and top of pit 60"to grade, pit was dry at time of inspection and staining indication water being.at 24.'at one point in time. t5insp•08106. Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 Black Duck Lane-West Barnstable, MA Property Address Martin Kennedy-6 Volunteer Road Owner Owner's Name information is required for East Sandwich MA 02537 11/12/2007 every page. City/Town 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 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.): 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.): t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15' .. .. Commonwealth of Massachusetts _ W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10 Black Duck Lane-West Barnstable, MA Property Address Martin Kennedy-6 Volunteer Road Owner Owner's Name information is required for East Sandwich MA 02537 11/12/2007 ' every page. City/Town 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. J' 4 . )W o al�GV) t5insp•08106. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts M Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 Black Duck Lane-West Barnstable, MA Property Address Martin Kennedy-6 Volunteer Road Owner Owner's Name information is required for East Sandwich MA 02537 11/12/2007 every page. City/Town State Zip Code Date of Inspection D. System Information•(cont.) Site Exam: ❑ Check Slope - ❑ Surface water ❑ Check cellar ❑ Shallow wells Zb / Estimated depth to ground water: feet Please indicate all methods used to determine the high groundwater 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: t5insp•08/06 Title 5 Official Inspection Form:.Subsurface Sewage Disposal System•Page 15 of 15 Permit Number: �Date: Completed by: ��/ HIGH GROUND-WATER LEVEL COMPUTATION Site Location: m X lad.�//GL� i Lot No. Owner: V Address: Contractor_ G Address: — Notes,: STEP 1 . Measure.depth to water table �7 J to neatest 1110 ft..................................... ........ :..:.:... ........ .........:. .Date. `/// month/day/Year STEP 2. Using Water-Level Range Zone and .Index:Well Map 1pcate site and determine: r y t A .Appropriate index.well,........: ........ ...:. ... �Ate.....:. OWater-level range zone ..::::......:. STEP .3 Using monthly report."Current Water Resources Conditions" determine current depth to water level for index well........................... L109 .. zy month/year STEP 4 Using Table of Water-level.Adjustments for index well (STEP 2A),current depth to water level for index well (STEP 3) and water-level zone (STEP 213) determine waterdeveCadjustment ...........,................................ ..................................:......... 6.. STEP 5 Estimate depth to high water by subtracting the water level adjustment (STEP 4) afrom measured depth to water level at site (STEP 1) ... ....... Figure 11--Reproducible computation form. 15 Cb G Town of Barnstable OF 1HE fps yP� Regulatory Services r r ,, AB Thomas F. Geiler,Director 16 9. •0� Public Health .Division rED MA'S A Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-8624644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts,Department of Environmental Protection. - Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition,by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the "Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. n COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIfflG=NMENrTA.I�PROTECTION „`� .c L r Ili22 2005NSTrtB LLDEPO EPT. OWN OF a � TITLE 5 HEALT OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM FORM PART A CERTIFICATION Property .Address: A0 ��,Cj e Owner's Name OwnWs Address: IQgA C,oy-,[c4,, )p 2, 10 Date of InspectionG-)4, ,ytp Name of Inspect • (please print) Company Nam z 2 Mailing Address: U R� c _(' 'ARC5t.. Telephone Number: 22 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(310CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by tie Local Approving Authority ails Inspector's Signature: � � Date: 104 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 sha:-ed 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 is the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of.I I 4 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 1 Property Address: Owner.vJZ Date of Insp tion: _J P ��. /J.ts^� �¢ O0o6 �T Inspection.Summary: Check- A,B,CD or E./ALWAYS complete all of Section D i A. S stem Passes: I have not found any informatio-,which indicates that-any of the failure criteria-described in310'CNIR 15:303 or in 310 CMR 15.304 exist:Ar_y.failure criteria not evaluated are indicated below. Comments: i B: System Conditionally Passes:. i 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: I i 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 over20 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 j indicating that the tank is less than 2.0 yzars old is available. ND explain: Observation of sewage backup o.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 obstmction is removed distribution box is.leveled or replaced i ND explain: j The system required pumping m-ore 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):. I broken pipe(s)are replaced j obstruction is removed i i ND explain: 2 r Page 3 of I'] OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued)., Property Address: 66&tz 4 ` r w ,e. 4. Owners, Date of Inspe on: ,;,�2�1 -A*4 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,w,ill,pass_ugless,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 a salt marsh 2. Systein will fail unless the Board of Health (and Public Water Supplier, if an 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 aseptic tank and SAS and the SAS is within E 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 D£P 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 cr less than 5 ppm,provided that no other failure criteria are triggered. A-copy of the analysis must be attached to this form. i . 3. Other: i a , f . 3 i 1 i I Page 4 of 11 r OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION:FORM PART A CERTIFICATION(continued) Property.Address: 14 Owner:,. Date of 1nsp on:,7,., A.41Q D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to ea& 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 l clogged SAS or cesspool i/ Static liquid level.in the distribution.box.lbove 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_rivy is within 100 feet of a surface water supply or tributary to a surface / water supply. J/Any portion of a cesspool or privy is within a Zone 1 of a'public well. Any portion of a cesspool orr privy is within 50.feet of a private water supply well. l/ 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 tAe analysis must be attached to this form.) (Yes/No)The system fails. I have determined that,one or more of the above failure criteria exist as described in 310 CMR 153 03,therefore the system fails. The system owner should contact.the Board of Health to determine what w_11 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 the-system is within 400 feet of a surface drinking water supply the system is within 200 feet zf a tributary to a surface drinking water supply the system is:located in a nitrogen sensitive area(Interim Wellhead Protection Area.—I WPA)or a mapped Zone II 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 I5.304,.The system owner should contact the appropriate regional office of the Department. 4 . I. Page 5 of I I i OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM FART.B CHECKLIST I Property Address: Q&h,p Q,Q_tt Q , 1 Owner. — ,I j Date of Insp ion: nhai 4-A,V�Q, i 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,o-Board of.Health _ V11 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 ? I Have large.volumes of water been introduced to the system reiently or as part of this inspection? Were as built plans of the system obtained and examined?(If:hey were not available note as N/A) I Was the facilityor dwellin `ms ected for signs of sewage bacl:u 9 g • p a 5 P r j Was the site inspected for signs of break out? ,C Were all system components,excludingt the SAS, located.on sire 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? ' i I i I The size and location of the Soil Absorption System (SAS)on the site has been determined based on: I Yes no Existing information. For example, a plan.at the Board of Health. ' i/ _ Determined in the field(if any of.the failure criteria related to Part C is at issue approximation of distance j is unacceptable)[310 CMR 15.302(3)(b)] t 5 r i Page of 11 1 i OFFICIAL INSPECTION,FORM_NOT FOR VOL'UNTARY°ASSESSMENTS F SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM INFORMATION r Property Address: JQ � ,d '✓`��'C c��v� (,C Owner:�l IL -Ae Date t of Insp on: os— LOW CONDITIONS RESIDENTIAL Number of bedrooms(:design):- .3. . Number of bedrooms(actilal): DESIGN flow based on 31 0 CMR 15:203 (for example: 11:0 gpd x#of bedrooms): IV Number of current residents % �/ Does residence.have.a garbage grinder(yes or no):,/ Is laundry on a separate sewage system.(yes or no):W..[if yes separate inspection required] Laundry system inspected(yes or no):Ye.� Seasonal use: (yes or no): ` .$... Water meter readings; if available(las_2 years usage(gpd)): 7hjda� 0 8yd Sump pump(yes or no): Last date of occupancy: i . COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR.15.20): gpd Basis of design flow(§eats/persons/sq�t,etc.): „ Grease trap present(yes or no): Industrial waste holding tank present ayes or no):— Non-sanitary waste discharged to the Title 5 system(yes or no):-_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the ins-3ection(yes or no): If yes, volume pumped: gallorts--How was quantity pumped determined? Reason for,pumping: 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) _Imaovative/Alternative tech_ nolog�.Attach a copy of the.current operation and maintenance contract(to be obtained from system owner) - _Tight tank Attach a copy'of the DEP.approval Other(describe): Approximate age of all components, dote installed(if known)and.source of information: Were.sewage odors detected when arr:ving.at the site(yes or no):_ [ Page 7 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) r Property Address:/C.) ( � Owner:�,-N- Date of Inspe ion: ,,P 4 cc)J BUILDING SEWER locate on site plan)A.(� ( P ) Depth below grade: Materials of construction:_cast iron ._40 PVC_other(explain):- Distance from private water supply well or suction liner _ Comments(on condition of joints, venting, evidence of leakage,etc.):- I SEPTIC TANK: (locate on site plan) Depth below grade: rQ,(� c3 Material of construction: v6ncrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age: 1s age confirmed by a Certificate of Compliance(yes or no):_(attach a'copy of certificate) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 361 Scum thickness:_[) Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom or outlet tee or baffle; `f How were dimensions determined: a4y-ez Comments (on pumping recommen ations(inlet and outlet tee or baffle condition, structural integrity, liquid levels r-as related to outlet invert, evidence of leakage,etc.): ( v t GREASE TRAP (locate on site plan) .Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: . Date of last,pumping: . �. Comments(on pumping recommendations,inlet and'outlet tee orbaffle ccndition,structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): II f 7 Page 8 of I 1 - i r OFFICIAL.INSPECTION FORM—,.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C f SYSTEM INFORMATION(continued). Property Address: A.fl�(> Ownerj, U Date of Ins ion: 7 J00 j' TIGHT or HOLDING TAN/1 (_ank must be pumped at time of inspecti.on)(locate on site plan) I Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallor_s j Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): II. DISTRIBUTION BOX: f/ (if reser-t must be o ened)(locate on site plan) p P Depth of liquid level above outlet invert:_ZL� &12A� Comments (note if box is level and distribution to.outle equal, any evidence of solids carryover, any evidence of le kage into or out of box, etc.): PUMP CHAMBE : (locate on s:te plan) j Pumps in working order(yes or no):.. Alarms in working order(yes or no): Comments (note condition of pump charnber,condition of pumps and appurtenances,etc.): j I I, I t. } i i j j I 8 Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEI\:7 INSPECTION FORM i PART C , SYSTEM INFORMATION(continued) Property Address: Own i Date of Ins, Rion_*.*_',_ j '! SOIL ABSORPTION SYSTEM(SAS):t/(locate on site plan,excavation not required) j -If SAS not located explain why: q li TYP leaching pits, number: leaching chambers,number: Teaching galleries,number: leaching trenches,.number, length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: 'i Comments(note condition-of soil, signs of hydraulic failure, level of ponding, damp soil;condition of vegetation, ! I� CESSPOOLS: (cesspool must be pumped as part of inspect ion)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: j Dimensions of cesspool: Materials of construction: i Indication of groundwater inflow(yes or no): 3 I. Comments(note condition of soil,signs of hydraulic failure,•level of ponding,'condition of vegetation,etc.) �I t PRIV (locate on site-plan) �I !' Materials of construction: ' Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.): i f r 9 i I i Page 10 of I I j OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM. PART C SYSTEM INFORMATION(continued)' j ,Property Address:. �-C� . s ,L Owner: t— ,g I Date of Insp ion: p - �QU j k 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 i i i i i a cc�a c,, IGo �i O 10 � it Page I I of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE,SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' - PART C " SYSTEM INFORMATION(continued) i Property Address:) � ,ZN�i, > l Owner Date of Inspe ion:tii�f/v1�1,/rv )� SITE EXAM Slope Surface water Check"cellar Shallow wells Estimated depth'to ground water feet if j Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: 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:- I You must describe how you established the high ground water elevation: a I t =' 11 I Permit Number: Date: rComp eted by: HIGH GROUND-WATER LEVEL COMPUTATION is j Site Location: �G C1c ��% Lot No. Owner: / �� Address:Contractor: - Address: �JN< y; G/�STt"�'� I. Notes: i i j STEP 1 Measure depth to water table Z /�� tonearest 1/10 ft. ................................. .. ....................................... ..... .Date I month/day/year i a ' STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determiner (AAppropriate index well.................................................... sz 'OPT. 1, C Water-level range zone ....................................................... j STEP 3 Using monthly report"Current Water Resources Conditions" determine current depth to ll water level for index well ....._........... ©/k i; "` month/year r ! STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 2B) determine water-level adjustment ......................: 1. . h STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water level at site (STEP 1) ................................................ .............................................................. i - i; 1 Figure 13.--Reproducible computation farm: At l 15 II i t, } I i_u. •r, 1{ 4 � .n i S UA .s r`v � 9 ry p BORTOLOTTI CONSTRUCTION, INC: a �l 765 WAKEBY ROAD,MARSTONS MILLS, MA 02648 508-771-9399 508428-8926• FAX: 508428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: Date of Inspection: Inspector'sName: er's Name and Address: CERTIFICATION STATEMENT: x I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of inspection. The inspection was per- formed b on my training and experience in the proper function and maintenance of on-site sewage disposal stems. The System: Passes Conditionally Passes -,Needs Further Eval n B t e al Aproving Authority ~; Fails. y Inspector's.Signature - 'Date: The System Inspector shall.submit a copy of this inspection report to the Approving authority within tWr- ty(30)days of completing this inspection. If the system is a shared system or has a.design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY A)SYSTE PASSES: - V Ihave not found any information which tndicates.that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. W B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system, upon comple- tion of the replacement or repair, passes inspection. ' Indicate yes,nor,or not determined(Y,N,OR ND). Describe basis of determination in all instances. If "not determined",explain why.not. The septic tank is metal,cracked,structurally unsound, shows substantial infiltration or 4 exfritration,or tank failure is imminent. The system will pass inspection if the existing sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup or breakout or high static water:level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The system will.pass inspection if(with approval of The Board of Health): i ow SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A f- CERTIFICATION(continued) Broken pipe(s)replaced Obstruction is removed Distribution Box is levelled or replaced The System required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(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 t 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 (ANDRUBLIC•WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT;THE SYSTEM IS FUNCTION- ING IN A MANNER THAT.PROTECT THE PUBLIC-HEALTH AND SAFETY AND THE ENVIRONMENT: , The system has a septic tank and soil absorption system and is within 100 Feet to a surface water supply or tributary to a surface water supply. The system,has a septic tank and soil absorption system and is with a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 Feet but 50 Feet or more from a private water,supply well,unless a well water analysis for coliforra bacteria and volatile organic compounds indicates that the well is free from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D)SYSTEM FAQ,S: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.363. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent to the surface of-the ground or surface waters due to an overloaded or clogged SAS or cesspool. •Static liquid level in the distribution box above outlet-invert,due,to an.overloaded.or clog- . . = f ged SAS or,cesspool:;w, L 4 N r ,. ..�.... .. Liquid depth in cesspool:is,less than 6"below invert or available volume'is less than 1/2 day flow,, Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped -2- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well: ; Any portion of a cesspool or privy is within 50 Feet of a private water supply well. Any portion of a cesspool or privy is less than 100 Feet but greater than 50 Feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen: E)LARGE SYSTEM FAE S: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 gpd or greater(Large System)"and the system is a significant 'threat to public health'and'safety and the environment liecause;one.ormore'of the following `conditions exist: . :,t. The system is within 400 Feet of asurface'drinkng`water`supply t " ` + 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 a ma ; ( )'�or peed Zone II of a public water supply�well.= The owner or operator of any such system sliall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00.' Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST:_ . Check if the following have been done: { _—IJFumping information was requested of the owner,occupant,and Board of Health. _done of the system components have been pumped for atleast two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. �As-built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up: The system does not receive non-sanitary or industrial waste flow .i The site was inspected for signs of breakout . {^"°h'• « wz' All:system.components,excluding,the Soil-Absorption System,have been located.on site. :. _,GThe septic tank manholes were uncovered,opened,and.the interior of the�septic tank was in- ; pectedfor condition of baffles or'tees,material of;construction;-dimensions,.depth of liquid, depth of sludge,depth of scum. r= - a 'The'size and location of the Soil Absorption System'on'the site has been determined based on existing information or approximated by non-intrusive methods. -3 r '. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) _IZThe facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM" PART C SYSTEM INFORMATION FLOW CONDITIONS RFSID .4T Ai Design Flow:,3,�:�gallons Number of Bedrooms: Number of Current Residents: Garbage Grinder: /UQ Laundry Connected To System: Seasonal Use: �?D Water;Meter Readings,if v Table: Last Date of Occupancy: r C0 ~M .R _ IC ALJIND T IAi:.. (� A._ f . x. .• ;„.., "' Type of Establistiment: Design Flow: - gallons/day`Grease Trap Present:(yes or no) Industrial Waste Holding Tank Present: g _ .. Non-SanitaryVaste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS andf source of information: " System Pumped as part of inspecdon:/-)Q If yes,volume pumped: gallons Reason for pumping: TYPE QF SYSTEM: Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records, if any) ). ' -Other(explain -;ROXIMATE AGE of all components,date installed(if known)and soutce'of.information::..:.,. age odors•detected when arriving of the site: Y -4 SUBSURFACE SEWAGE UISPOSAL,SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) ' �It✓� CoUer /���� G��� SEPTIC TANK: . ✓ Cotter� 3 y �J . Depth below grade: Material of Construction:_ concrete metal FRP Other (explain) Dimisions:2t,S'7(Cam'Xcs' Sludge Depth: " Scum Thic�kn ess: Distance from top.of sludge,to bottom .of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: i[/Odt Comments: (recommendation for pumping,condition of inlet and outlet tees or b es,depth of ligt»d level in relation to de t invert, structural integrity, evidence of leakage, etc.) ; 191, GREASE TRAP: 1 Depth Below Grade: Material of Construction: concrete metal FRP Other,y (explain) _ -- — — w Dime _ nsuons: '.'.'_.��. - .�,. Scum Thickness`. � r- Distance from top of scum to top of outlet tee or baffle: ,- Comments:(recommendation for pumping,condition of inlet and outlet tees or batlles;.depth of liquid ,-- level in relation to outlet invert,stnuctural mtegrily evidence of leakage etc) TIGHT OR HOLDING TANK:_.AZO Depth Below Grade: Material of Construction: concrete . . metal° FRP—Otiter(explain) Dimensions: Capacity; gallons Design Flo«•: gallons/day Alarm Level: Comments: (condition of inlet-tee;condition of alarm and float switches, e(c.) DISTRIBUTION BOX: Depth of liquid level above outlet invert: Comments: (note if 1 el and distribution is equal,evidence of solids carryover, evidence o leakage into or out of box,etc.) l41 - PUMP'-CHAMBER _ -Pum is in g order: , . �.s,:,. t r �.,,.1. 8 ` k - ♦ c Comments: (note condition of pump chamber;condition of punips "!id a'ppurte'naiices-''ttc. a • V SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) SOIL ABSORPTIO14 SYSTEM(SAS): t� (Locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: Leaching pits,number:/Leaching chambers, number: Leaching galleries,number: Leaching trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool, number: Co uts:(note condition of soil,signs f hydraulic failure level of nding,co ition of vegetation, etc. f CESSPOOLS: Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of Cesspool: Materials of construction: , ` Indication of groundwater: Inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soilk, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) PRIVY:. Materials of construction: Dimensions: Depth of Solids: Comments:(note condition of soil,.signs of hydraulic failure,level of ponding,condition of vegetation, etc.) -6- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. , Locate all wells within 100 Feet. t, �O t.k'}1.� .-�'it] .Y.�,. .��u.qt y,•fE;'f �1 Y,y:t Y J.!^•.:�';' DEPTH TO GROUNDWATER: Depth to groundwater: Feet Method of De rmination or App oxim don: ^ i y 7 1.. .. ,, TOWN Orl�BARNSTABLE 'LOCATION/O �'t,(�� l � �C1llX.P SEWAGE # -/ VILLAGE w/II&Azwl ASSESS/O�R''S MAP & LOT�3 Z7vzTL14 : µ.NAME&PHONE NO. SEPTIC TANK CAPACITY �� LEACHING FACILITY: (type) offAAh- )-._.e� C>� (size) f60G2.�vih NO.OF BEDROOMS BUILDER OR OWNER �i 112� 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 on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by _ � y En: V� w *TOWN OF BARNSTABLE O LOCATION 6ff—14v*( $LAf9,Q6C'it- 44AJ� SEWAGE # 77- %lo,9 VILLAGE (,U ASSESSOR'S MAP & LOT.-A37- -/ INSTALLER'S NAME & PHONE NOK f e2am ,v"i77 CONS SEPTIC TANK CAPACITY /OGG LEACHING FACILITY:(type) L�.4-11IA° P.777- (size) ocda NO. OF BEDROOMS_,_:? PRIVATE WELL O PUBLIC WATER BUILDER OR OWNER ,ORL I-ivtw*,-j &, E DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No 'x � � ti Fss.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH lt-�t OF............ : ... .. . -- ................................. Appliration for M-4pasal Workii Tomatrnrtiun rrmi# Application is hereby made for a Permit to Construct (>e). or Repair ( ) an Individual Sewage Disposal stem at r�Lo�...... l . W i O et QI w0*� Address Installer Address AA Q Type of Building Size Lot... -----Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( } Other—T e of Building No. of persons.......................... Showers " a YP g --------••-----•------------ P -- ( )•-- Cafeteria ( ) QOther fixtures ------------------------------------------------•-•----•----•-••-•--------•-••-•---•-•-...-••--••• .................................................. Design Flow............................................gallons per person per day. ,Total daily flow..............................................._._.............._._.gallons. WSeptic Tank—Liquid capacity gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No_ ____________________ Width... Total Total Length..........y..._.__ Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet....... Total leaching area_-_�M 15.sq. ft. Z Other Distribution box Dosing nk ( ) Percolation Test Results Performed b --__ e�.r. ers `._ �' �� W . ---- Date-- --_.... Test Pit No. 1__ _ .. minutes per inch Depth of Test Pit....�3`.._......._ Depth to ground water__�^"`^.�......__. f� Test Pit No. 2...�.�'_._minutes per inch Depth of Test Pit.._..r ..__...... Depth to ground water---- ---•• ..................................... 0 Description of Soil------. `'' ...,It........................................ j---------------------------- ........................................... ---------------- •------------------------ •---------------------------------------------------- •------- --------------------------------------------------W UNature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescri Individual Sewage Disposal System in accordance with the provisions of iTIE ' , p 5 of the State Sanitary Co e— he ersigned further agrees not to place.the system in operat- n until a rtifica�ompliance has be issu by of health. \\" Signed. ........ ••............. ...........................•-----..._..•-----•-••-•--•- Date ApplicationApproved By--•-----•-•--•--••••••••••-••-................................................................... 7-------- Date Application Disapproved for the following reasons:•------.....................................................------------------------------------------------•-- ..•-••••--------•-•----•------•------------•-•--...--•••---••-•-----------••-•-----------------------------•••_.....__...•-•--------•-•--------------------••------------•------•------•-•--•--•-------. Permit No.... _:.A6, .............................. Issued._......at 2��A!!) / e .................... No......................... ........... . .... THE COMMONWEALTH OF.MASSACHUSETTS ` BOARD OF HEALTH w.....OF.-...-....--,.a . �: � Le -----•.................. Appliration, for Disposal Works Tunstrurtion rumit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal. (§;'yVem at Xr— ................_ .... ............_.......-•--••--•---•..............._ .................................................... ................. ........ .-•-•-•----•-------- r Location-Ad`r�ess or Itot No r- oLier ,, ^Address Installer Address UType of Building Size Lot___` __, _�' .....Sq. feet Dwelling—No. of Bedrooms_____________-_____________________.______.Expansion Attic ( ) Garbage Grinder ( ) '_l Other; Type of Building No. of ersons____________________________ Showers — Cafeteria a YP g P ( ) ( ) a Other fixtures ---------------------•--•-•--•-•-'-•-------•-- d --------- -------------------••-•••••••••'-••••-'--..................................... Design Flow...................._.......................gallons per person per day. Total daily flow...........?_ _:____._.._______.......gallons. WSeptic Tank—Liquid capacity....___._�I gallons Length....:........... Width................ Diameter................ Depth................ Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area-------------------- ft. Seepage Pit No..... Diameter_...__1q__________ Depth below inlet______r______.___: Total leaching area__.' `+�_sq. ft. Z Other Distribution box ( ) Dosing tank ( ) a Percolation Test Results; Performed.by--•--._....---••-••=•-••••••••••-••••--:�-'--;•----•••••••••-•-•--_._. Date......... ------ --------- ......... 44 Test Pit No. 2......... _._minutes per inch Depth of Test Pit.................... Depth to ground water----`_­___ O I x i' e ` �_ ................. _-• .Description ' .: `v of Soil __. ---- ........ -•----U ........... W U Nature of Repairs-or Alterations-Ari,,wer when applicable__ _______________________'_._____._____.____._.___.__..._._..._.._.___._._.:___.__._______.. •r:, Agreement: t The undersigned agrees to install<the aforedescribed Individual Sewage Disposal System in accordance with 41 of the State'Sanitary Co,�2'e he ersigned further agrees not to place the system in the provisions of Ti operattil a C rti$cate of Compliance has be > su by of health. Signed---•----....7=-- ----------------------------------------•----------------------- Date Application pproved By--••--•---:..---- " - ................................. -•-•--•• Date Application Disapproved for the following redsons:----'-•-----•••"•--•-•••----•-____.•-•-•--•••••'---•-•••••--'--------------•--•'••-•••----•••-•-•-••:........_ Permit No......9.7-le; -----_-_-. Issued...... ...,; `/ 1 ____'............. ate---...__...........a..----•-• THE COMMONWEALTH OF MASSACHUSETTS ,' BOARD OF HEALTH • .. ...........OF...... Qprrtifiralr of TompliFanrle THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed .) or Repaired ( ) y-------•--&� �- -- - - Q .• Installer at......441 ...... t�4 ----------•-------•-------------•---•--•---•------••------------...._._..--•--•----•-----•--------------•-------------- has been installed in accordance with the provisions of TIME j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No_________________________________________ dated----------...................................... THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL `FUNCTION SATISFACTORY. DATE................. ............................ Inspector................. ..... ................................................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............OF....-..... G�rrrn .: NO._ 1• .1. .1-.__. FEE..:/ .... Disposal Works Tuonsir n �nmit s t 1's Permission is hereby-granted..,... ... f -•-••••-==--• - { to Construct �1) or Repair-( ) an I'irdivid Sewage Disposal System atNo. •-•-•---_._..--•----•-•----------------•--------•-•--=-••-••-___........ Street as shown on the application for Disposal Works Construction Permit No.271 b __ Dated_.___3:.....:.t__3- ___5i_.7.. ' v � ......_ C - ---------- - Board of Health DATE . ----••'-- n = ............... "I _ FORM'1255 HOBBS & WARREN, INC., PUB ISHERS 6 I'm lop Fr�c/ O ro 66 'v ! 6 'f J (p2 2.00� .�? p h 1.4 is l.fo up , i , 1 � � "O TE _ e�c/sf/nq 9,-OWnce/ prof!/e - EXTEA/L� AGL APPLlCA BLE o---o—o—o•— proposed around prof`!/e HOre/z. SG,9LE: C T 0 N --- '- ' VE i2T. SCALE: / - /O MAA/H0l-E COVC=A2s TD WITHIAj t �r»in. %4•pe�,�-f;� FL OW2" layer of SCH&D. 40 PVC . ore �ln/n/mum l� 3/ems peasfone . EQUfIL To SEPTl c t 6d TANK . r1' J 6 Sum 314•-/%z" C.'.r� I:p was had xvfw e /OCOO GAL. SEG'T/C TAA Ad L EACH P/7' C ,al /O DATE. is Aucc +gS TEST s Ml' .intc. 1 BET��ooM HouSE _ .. no di sar ,0 . 4 '-rd• .. � _ . __ -c w/Tn/ESS. Ga.yLo/y' QATE- z� M/!�/. /A/CH 9 DRI . . / FL # ZL- OW2AT� 3 GALSP2 p : 0 'vE� A C3.7 , F ON / + rip D . $Ef�7"/c 7i9Nk : 33r' x /.5 4�So pep, L:0A' ; LOA _ — 1 ��N a USE : M_ I boo o GAL. TF-itil,� � � SC(B5C2IL . 2' 7 _.. C-E f9CH/NG A r2 r=,9 5/DE.Ah9LL; i8s.6 x 2 . S a 4>l. 25 6.P.D, :,S�9t�.h._, _:5-A0D OI 0 o ` c, TOTf9 C. • 549.767 G.P.D. N �.�t UsE (�) �,'x�' �. Egcrl P�7- w .2' o,- sr�nr RAYS . :BDta �R� 'F30UGDR 8616 . 10 d cERTIF)' THAT THE 8v/GD/iIJ4S nio HZ.Q_ IJcounlTa�fl N v H,o � Icoy�►T>~RD . s- / e ��:�� � ...- � -• p PROPOSED ON THE Gr20UNb AS , lOA SHOWN ON TH/5 PLAtiJ DOES C0AJF0rQM TO THE 8U1LD/hJG SET Sl TE - .S E4-JA GE PLgI I`.I --- • 6rg 66 RE ouI.QEMEAi r6 OF 7'HE 70WAJ of - - - OF/Ass . q GEOPGE C ; PR T p LOW > `yam EPARED FOR: oH^1 L O 1, SIMARD eG�SZ`���-1 / No. 4700 y / SCALE AS NOTED DATE: Vtl Q-�7 �of• E �� �, ._. SCALE, /.. • ,��) �� ' PL.Ati C VIEW s.�% z9,i9�� o. 00 exlsflnq a/eva'fion D�TE SLDG. 5ET,BAC/G o.'ao l-o osed- e o vatior� i2E 0U/REMEI�,JTS � _ —••.....a..— c t 3o F'f MASS• LQ GJELL E2, Inc. X/s�-lnq con-four-s 130, cD OF HEALTH T�l4 /"!A/ti STeEEs! de onf0Urs , YARMOUTH p0,2T, MASS . 1!rl rear = rr PROFE55lOIlJAL ErV6lNEERS fr LAND SL42VEY0+25 - ._ a r t i 'V . . a.