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HomeMy WebLinkAbout0014 BRENTWOOD LANE - Health 14 BRENTWOOD LANE, �m o COMMON 'EALTH OF NIAS-SACH SE I"''S EXECUTIVE OFFICE OF ENvikoNiMENTAL AFFA Rs DEPARTMENT OF ENVIRONMENTAL PROTECTION ♦ N TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE; SEWAGE DISPOSAL, SYSTEM FORM PART A CERTIFICATION Property Address: Owner's Name: . Owner's Address: a 437 Date of Inspection: Name of Inspector:(please print} Company Name: Alf A°Mailing Address: 4 VVW r+S�w� Ro w Telephone Number: .SIB .���$'-7— a� �..G: .:t CERTIFICATION STATEMENTS I certify that I have personally inspected the sewage disposal system at this-address and that the inko nation reported°,$ below is true,accurate and complete as of the time of the inspection_The u spection was performed used onrMy M 4n) training and experience in the proper function and maintenance of on site sewage disposal systems_ am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by theLocai Approving Authority. Fails Inspector's Signature: 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. 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 I Page 2 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: - 4 NfOl�a�u/ Owner: Date of Inspection: 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 n be replaced or repaired.The system,upon completion of the replacementZapoved by oard of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the fatements.If`dot determined"please explain. The septic tank is metal and over 20 years old*or tether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltrationinent.System will pass inspection if the existing tank is replaced with a complying septic - approved by the Board of Health. *A metal septic tank will pass inspection if it is cturally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years o is available. ND explain: Observation of sewage b or break out or biigh static water level in the distribution box due to broken or obstructed pipe(s)or due to a ken,settled or uneven distribution box.System will pass inspection if(with approval of Board of Heal : broken pipes)aye replaced obstruction is Temoved distribution boot is Lvieled or replaced ND explain: e system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pas ' spection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page?of`' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: / Owner: r Date of inspection: C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in orde o 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 ' 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public h th,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 vegetal wetland or a salt marsh 2. System will fail unless the Board of Health(a Public Water Supplier,if any)determines that the system is functioning in a manner that protects a public health,safety and environment: _ The system has aseptic tank and soil sorption system(SAS)and the SAS is within I00 feet of a surface water supply or tributary to a s ce water supply. The system has a septic tank SAS and the SAS is within a Zone i of a public water supply. The system has a septic and SAS and the SAS is within 50 feet of a private water supply'well. _ The system has a sep ' tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply we *.Method used to determine distance "This system p if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and vol le organic compounds indicates that the well is free from pollution from that facility and the presence ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure crit a are triggered.A copy of the analysis must be attached to this form. 3. Other: .a 3 I Page 4 of l l OFFICIAL INSPECTION FORM--NOT-FOR VOLUNTARY ASSESSMENTS 17 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.A CERTIFICATION(continued) Property,Address: t(7� �itJGind Owner: _ Date of inspection: 6 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 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'h day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public 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 iU0 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 coMm 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 twor less than 5 ppm,provided that no other failure criteria are triggered.A copy of the 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 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: QT�o(�be considered a large system the syste _ serge a facility with a design flow of 10,000 gpd to 15,tgl0 Ord' '. You must indicate either"yes"or to each of the following: (The following criteria apply to systems in addition to the criteria above) yes no the system is 400 feet of a surface drinking water supply _ — the syst is within 200 feet of a tributary to a surface drinking water supply — , th ystem' is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped ne H of a public water supply well If y ve answered"y+es"to any question in Section E the system is considered a significant threat,or answered M es"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 CkAK 15.304.The system owner should contact the appropriate regional office of the Department 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: u fall Owner: Date of inspection: 91 V7 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 is 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? q Were all system components,excluding the SAS,located on site? T _ 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 L-n-Wnce of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Y no Existing information.For example,a plan at the Board of Health. _ Determined in the field(if any of the failure criteria relate_d to Part C is at issue approximation of distance is unacceptable)[310 CMR 15302(3)(b)) 5 Page 6ofI OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: i . Owner: Date of Inspection: :a42k767o FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_Z Number of bedrooms(actual):, 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 3 AD Number of current residents: R Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no): if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no):1 Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no):AV Last date of occupancy: C.V ' f COMMERCIAL/INNDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): dpd Basis of design flow(seati/persons/sgft,et Grease trap present(yes or no):, Industrial waste holding tank p (yes or no): Non-sanitary waste discharge o the Title 5 system(yes or no):_ Water meter readings,if ilable: East date of occupanc se: OTHER(desc ' ): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or 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) Innovative/Aitertiative technology.Attach a copy of the current operation and maintenance contract(to be ob_tained 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: s� s ` Were sewage odors detected when arriving at the site(yes or no): 6 Page 7ofil OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM. INSPECTION FOIL€ PART C SYSTEM INFORMATION(continued) Property Address: fr- T i� Owner: W Date of Inspection: BUILDING SEWER(locate on site plan) _ Depth below grade: Materials of construction:_cast iron _Y40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: � (locate on site plan) Depth below grade: Material of construction: concrete_metal_fiberglass polyethylene other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions: I&b Sludge depth: a2 it a Distance from top of sludge to bottom of outlet tee or baffle: c3� Scum thickness: 3 11_ u Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or bile: e How were dimensions determined: M'ok ey t`P Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related t outlet invert, vidence of leakage,etc. : k +' V s ('+ &&2 4 GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concret ____metal fiberglass__polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of sc to top of outlet tee or baffle: Distance from bottom scum to bottom of outlet tee or baffle: Date of last pumpin Comments(on pu ing recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to out invert,evidence of leakage,etc.): 7 e - f Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE]DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: f Owner: Awa r^ Date of Inspection: 3 a6 TIGHT or HOLDING TANK: (tank must be pumpe time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete me fiberglass polyethylene other(explain): Dimensions: Capacity: gall Design Flow: Ions/day Alarm present(yes or no): Alarm level: Al in working order(yes-or no): Date of last pumping: Comments(conditio f�larm and float switches,etc_): DISTRIBUTION BOX: d( (if present must be opened)(locate on site plan) Depth of liquid Ievel above outlet invert: -Q 1/44 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into pr out of box,etc.): p Gay tAja S r Pl/,��s,� LS �uj ccx r#tt PUMP CHAMBER: (locate on site pl Pumps in working order(yes Alarms in working order(yA®rno):. Comments(note condition hamber,condition of pumps and appurtenances,etc.): 8 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY A sSESSME �'TS SUBSLYI&ACE SEWAGE DISPOSAL SYSTEMI'INSPECI'ION FORM PART C SYSTEM INFORMATION(continued) Property Address:—!��ZrywYwaj Owner: Date of Inspection: 146 SOIL ABSORPTION SYSTEM(SAS):_jj�_(locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number leaching chambers,number leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Typeiname of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): ' � t 'N, CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet inve Depth of solids layer Depth of scum layer- Dimensions of cess Materials of co tion: Indication of gr dwater inflow(yes or no): Comments( to condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate o e plan) Materials of co ction: Dimensions: Depth of s ds: Comore (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 i Page to of I l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: SKETCH OF SEWAGE IDISPOSAL 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 yo �n 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- ea V t Owner: Date of Inspection: c3 SITE EXAM Slope �eg Surface water Check cellar Shallow wells t� Estimated depth to ground water, =,V feet 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: You must describe how you established the high ground water elevati n: I I1 \ COMMONWEALTH OF NIASSACHUSETTS ExECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS4? I_ l� DEPARTMENT OF ENVIRONMENTAL PRO tECTIO1, ` I qq ONE WINTER STREET. BOSTON. MA 02108 617.292- WILLIAM F.WELD :.- r rRUDt COX Govemor - Seuetan ARGEO PAUL CELLUCCI - DAVID B.STRUHS AL Lt.Govemor SUBSURFACE SEWAGE DISPOS SYSTEM INSPECTION FORM Comtai�oncr 3 33 PART A CERTIFICATION a '/ a Property Address ,1 '� l/eJG�d Jew. e�UK� Address of Owner:.. s�� "v Date of Inspection: (If different) Name'of Inspector: I am a DEP approved system inspector-pursuant.,to Section 15.340 of Title 5 (310 CMR 15.000) 4 � Company Name: -. ��(a Ocam'T C'v Mailing Address: A6 Al )7-PAW Telephone Number: �rnF VV-F F#AF CERTIFICATION STATEMENT I certify that I have personaliv inspected the sewage disposal system at this address and that the information reponed•below is true, accuse and compiete as of the Jme of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposai systems. The system: Passes x _ C.onditionaily Passes _ Needs Further Evaluation By the Loll Approving-Authority Fails Inspector's Signature: Date: The Svstem Inspector shall ubmit.a copy of this inspection report to the Approving Authoritv within thirty (30) days of completing this inspection. If the system is.a.shared system or has a design flow of-10,000 gpd or greater, the inspector and the system owner shalt subrrnt the retort to the aooroeriate resionai office of the Department of Environmental Protection. The orternal should be sent to the system euurter and copies sent to the buver.Ji applicabie, and the approving-.authority. 'fNSPECTION SUMMARY --.Check A' B,­C, o� D ' I 'SYS EM PASSES I have not found any information whiCt indicates that the system violates any of.the failure criteria as defined in 310 0AR I S 3Z3. Any failure criteria not evalyato are indicated below.. a r/ g COMMENTS: If JAI 400i) ' U ' ,.r BI YSTEM CONDITIONALLY PASSES: One or stem components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the rep ac re ir, as approved by the Board of Health. will pass. indicate ves, no, or not determined (Y. N, or NDI. Describe basis II instances. If"not aetermined", explain why not. _ The septic tank is metal, uni ner or operator has prov,deo ;he syste or with a copv of a Certificate of Corr.ohance indicating that the tank was installed within r%venty ;=01 years prior :o of the tnspecrion; or t . tic tank, whether or not metal, is cracked. structurally unsound. shows substantiai -raiitratton or exit or tank failure is imminent. The system will pass inspection ,f the existing septic tank is repiaceo w;th a conforming septic tank as aooroved by the Board of Health. .revered J4'_S 971 Page 1 of 10 vE?^n:ne-voC-j vhoe weo nr,,,N+ww nagner stale ma-s.-,ec i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: B] SYSTEM CONDITIONALLY PASSES tcontinued) e backup or breakout or high static water level observed in the distribution box is due to broken or royal of he pipe(s) or a broken, settled or uneven distribution box. The system will pass inspect; pp Board of Health). observations: broken pipe repiaced obstruction is remove distribution box is ley or laced ore than four times a year due roken or obstructed pipe(s). .The system will pass The'system requi ping m inspecti with approval of the Board of'Health)::,'_' broken pipe(s) are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THEY BOARD OF HEALTH: �'t ; _� onditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to prote the pu i health, safety and the environment. 1) SYSTEM WILL UNLESS 80ARD OF HEALTH DETERMINES THAT THE SYS 15 OT FUNCTIONI IN A MANNER WHICH WILL PRO HE PUBLIC HEALTH AND SAFETY AND THE ENVIRO _ Cesspool or privy is within feet of a suraece water _ Cesspooi or privy is within 50 fee a bordering vegetated wettai`iu or a salt rth. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALT D PUBLIC PUBLIC HPPLIER, IF EALTH AND SAFETY AN DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PRO ENVIRONMENT: within 100 feet to a surface water supply or _ The system has a septic tank and soil ab n system (SAS) and the SA tributary to a surface water supply. Iv well. _ The system has a septic tank and absorption system and the SAS is within a Zon f a public water supply _ The system has a septic tank d soil absorption system and the SAS is within 50 feet of a ate water supp _ The system has a septi nk and soil absorption system and the SAS is :ess than 100 feet but 50 or-more from a private water su well; unless a.well water analysis for colifonn baceria and volatile:,organic compou y dicates that the well is from pollution from that facility and the 'presence of*ammonia -nitro nn aval d)trate nitrogen is equal to or less n 5 ppm. .Method,used co determine distance (aPP 3) OTHER Page 2 0! �0 _ev:.aed 04::5/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) _ Property Address: Owner: ^,a M r Date of Inspection: DJ SYSTEM FAILS: You t indicate eir er "Yes" or"No" as to each of the following: ave determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for is determination is identified below. The Board of Health should be contacted to determine what will be n essary to correct the fai e. Yes No , Backup sewage into facility or system component;due to an overloaded or clogged 5 or cesspool. Discharge or p ding of effluent to the surface of the ground or surface wai due to an overioaded or clogged SAS or cesspool. Static liquid level in the tribution box above outlet invert d o an overloaded or dogged SAS or cesspool., Liquid depth in cesspool is less an 6" below invert available volume is less"than-!,-2 day flow Required pumping more than 4 times the year NOT due to clogged or obstructed pipe(s). Number of times pumped Amy portion of the Soil Absorpt' System, cess of or privy is below the'hieh groundwater elevation. Am portion or a cessp or privy is within 100 feet o• surface water suppiv or tributary to a surface water supply. Any portion o cesspool or privy it within a Zone ['of a pu is well' Am• rtion of a cesspool orprivy is within 50 feet or a private wa supply well. Any portion of a cesspool or orivy is;ess than 100 feet but greater than 5 feet from a private water supply well with no acceptable water quaiiry anaivsis. If the well has been analyzed to be accep le. attach coot' or well water analysis for coiiform bacteria. volatile organic compounds, ammonia nitrogen and nitrate nr ogen. Ej LARGE SYSTEM F il.S: ?'ou,most in ' - e'e+men`"Yes orc No ;as;to each'of the ?o+lowin ::. m :.. .: . ..;. The`follow+, sueria aoph�,,toJargesystems.in,aaa+por, to the criteria above:=' The system serves a :aciliry h a design tlow'of 10.000 gpd'or greater-(Large Syste the�system is a.significant threat to public health and safety and the a onment because one or more or the f +ng conditions exist: Yes No the system is within 400 feet of a s ce drinking er supply the system is within eet of a tributary to a surface drinking ter supply the sv is located in a nitrogen sensitive area (Interim Wellhead Protectio rea- !WPA) or a mapped Zone II of a +c water supply well) .The ow or operator of am- such system shall brine the system and facility into full compliance with the er 6Nater treatment program reow+rements of 314 :_,viR 3.00 and 6.00. Please consult the lour ree+onal orrice of the Department 'or artier mrormaaon. ,rev-_sed 04/25. Page 3 of 10 s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: S��lgGr Owner: Date of Inspection: Check if the following have been done: You must indicate either "Yes" or"No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have.not been introduced into the system recently or as part of this inspection. As built pans have been obtained and examined. Note they are not available with N/A. ll _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered; opened, and the interior,of the septic tank was inspected for condition of baffles or tees, materiai of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and to ation of the Soil Absorption System on the site has been determined based on: ,, ry I _ The facility owner (and occupants, if different from owneri were provided with information on the proper maintenance of Sub-Surface Disposal System. _ Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [1 5.302(3)(b)J (rav:aad 04/25/97) page 4 Z: :0 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: 3 Jh> p.d./bedroom for S.A.S. Number of bedrooms:-3— Number of current residents: Garbage grinder(yes or no):_Y& t 'Laundry connected to system (yes or,no): :. . . Seasonal use (yes or no): ` :Water meter readings, if available (last two (31 year usage !.gpd) /✓R Sump Pump (yes or no): L + ry „ , Last date of occupanc­,1:_nzWVr COMMERCIAUIN DUSTRIAL: Type of establishment: Design Flow: tailons/day Grease trap present: (yes or noi_ , Industrial Waste Holdine Tanis present: Ives or no)_ Non-sanitary waste discharged :o the Titie 5 system: Ives or nol_ Water meter readings, if available: Last date or occupancy:,' # - =•- - r' •tom• v: ,<� ��,• _ . ., , - OTHER: (Describe) Last date of occupanc%- .. . GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as hart of inspection: tees or no:_ If yes, volume pumped: ealions Reason for pumping: TYPE 9F SYSTEM N/ Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (it yes, attach(previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all,.components, date installed (if known) and source of information: G ya •rZ(' 04a Sewage odors detected when arriving at the site: ;yes or no)�p vl revised 04/:5/97) Page 5-of :0 > SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not deti rmined to be present, explain: Tvpe: leaching pits, number: leaching chambers, number:_ " leaching galleries, number: , number,length:._. ,.. , leaching.-trenches, W. . . . _._._. .. . .._. . . � ...... , ._.,... leaching fields. number, dimensions: - overflow cesspool, number: Alternative system: Name of Technology: J Comments: (note condition of soil, signs of hydraulic failure, level of ponding, Condit on of vegetation, etc.) L SSPOOLS tlo to on site,piar+) f Number a configuration: Depth-top of id to inlet invert: Depth of solids la Depth of scum laver. Dimensions of cesspool: Materials of construction: "Indication of groundwater: inflow (cesspool must be pum c as part of inspection) Comm ents: _. _w.. •. i • .. ,. (note condition of soil, signs of hydraulic failure, level on g, condition of vegetation, etc.) PRIVY:_ (locate on site plan) Dimensions: materials of constru n: Cepth of solids: 1 Comments: mote a ition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc. „ Page B o: 10 k_evieed 01/:5/97. i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspeciion: ING SEWER: (Locate on Ian) Depth below grade: Material of construction: _cast iron _ C _oth Distance from private wat Weil or suction line Diameter Comments: ;condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: (locate on site pian) Depth below grader Material of construction: Voncrete _metal _Fibergiass _Polyethylene other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compiiance ,Yes/,NO) Dimensions: 1O0U Sludge depth: '-� u Distance from top of<_iudee to bottom of oIr utlet tee or baffle: Scum thickness: S' be N Distance from top of scum to top of outlet tee or baffle:�_ Distance from bottom of scum to bottom of outlet tee or battle:_ How dimensions were determined: Comments: dition of inlet and outlet tees or¢arrles. depth of liquid )evel'iri reiation to outlet'inveri: structucsi• Irecommendanon for pumping, con Vp integrin,' evidence of ieakage, etc:) AA71sN U�J / GRE. TRAP• ,•...._. _.._.,.. . .... .,.. -... _..... . ...._ �.... (locate on plan) �. e ......_. ... ... ..• 4.•.. >... 4'"d •C . 1. f •.a..1'.°4• Depth below grade Material`of construction: crete metal.. Fiberglass _Poiyeihylene"_otheriexpiair,;•. Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or o e: Distance from bottom of scum to bottom of outlet tee o e: Date of last pumping: Comments: (recommendation fo ping, condition of inlet aril outlet tees or bafties. depth 'quid !eve) in relation ;o outlet invert, strucurai integrin•, evi nce of leakage, etc.: Page 6 o! 1C (:evicted 04/:S,'37' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: T OR HOLDING TANK: tank must be pumped prior to, or at time, of inspection) (locate o Ian) Depth below grade: Material of construction: _concr metal _Fiberglass _Polyethylene _oche plain) Dimensions: Capacity: gallons Design flow:_,_,_gallonsiday Alarm level:__,__Alarm in zing order _Yes;_ N� Date of previous pumping: Comments. (condition of i tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert:_ Comments: (note if level and distribution is equal. evidence of solids ca�'tiver, evidence-of leakage'into or out of box, etc) yz PUMP CHAMBER:_ (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.) Page 7 of 10 (revised 04i25i97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: r'(� SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house)' y 31 40 /000 DJS' 0; '10 t• ' _r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _r PART C SYSTEM INFORMATION (continued) ` . s � Property Address: s . Owner: 't Date of Inspection: Depth to Groundwater 1,4 Feet yLUf ' Please indicate all the methods used to determine High Groundwater Elevation: IObtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.! Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators. installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) rQ. (revised 04/25/97� Page io of mom ° �'•G-, i �� . � �'" ,• sty.t►�J a�� `uP��'- ��' ' VVTTom vim. 40GA'C7� `". Aln !,�s. I �a M�1 f d.�hS.. ��"`4 ' D�! �� ,r(+�1� C• ; ` R :s PETER SULLIVAN tnN TF 0, AO INV MIS ' , ; o���• ,'��� �s:sue`�✓;:w r 4 SAL.; eoo t U546U& k 2 � ,t�: oi? fAt4rl 1� I�oc. -� r tME.. ' tom. AF 14 FEW • � �. NN tJ' S4 Ti �L•rU''1� J� WER SULLIVANaM LAP- J�Ewg. F ` 03fj F Vic. J,,H TOWN OF BARNSTABLE LOCATION C.c� - �i�EWAGE # VILLAGE u mwk �L , ) ASSESSOR'S MAP 6 LOT 33,3- ®3® INSTALLER'S NAME & PHONE.NO. -" SEPTIC TANK CAPACITY ® -c:2 LEACHING FACILITY:(type) eT_ (size) NO. OF BEDROOMS PRIVATE WELL OR ' UBL1C WATE, BUILDER OR OWNER C� DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No / o `� s� �� �� � #�� �a ���`y� • Y - •y.� .. �� �_ . 333 - No... a? a...� FEB ........... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ! TOWN OF BARNSTABLE Appliratinn for Uigpuual Works &'ni .trnrtinn mit Application is hereby made for a Permit to Construct (X ejor Repair ( ) an Individual Sewage Disposal System at: ....-------- ---...------••------------------------------- -----•....------------•--.....--------...--•------•----------------------.............----........ tali - ddress j. y�+Q /9r/jqt o l� ................... Sr/�+....Y...E.-_-__..__....... Owner Address a n_ .ISCULL !�? . �YlILLS Installer Address 4/1 d Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.....................:........•.....__......Expansion Attic ( ) Garbage Grinder (Vo aOther—Type of Building No. of persons............................ Showers ( ) — Cafeteria ( ) 0 Other fixtures .....................................6 W Design Flow...................t!�U.................gallons per er day. Total daily flow.._....._3`3p...__....____..........gallons. WSeptic Tank—Liquid capacity.101?gallons Length.... ... Width..° ,. ... Diameter_S'5"`"'.. Depth................ x Disposal Trench—No..................... Width.................... Total Length.....3.I......... Total leaching area............_.___--sq. ft. Seepage Pit No--------------------- Diameter----10......... Depth below inlet..........9........ Total leaching area.a yS_._._sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by---•----------•--------••••---------------••-•.....---------- ••...... Date........................................ Test Pit No. 1..<__a-.._minutes per inch Depth of Test Pit.J3........... Depth to ground water....../-ON -- (s, Test Pit No. 2................minutes per inch Depth of.Test Pit...:................ Depth to ground water........................ .................................-. ......................................... 0 Description of SoiL0. - Ztur.Gl __ y; ........................ -� ..... U -------------------------------------- ------------------------------------------- •----------------------- ------------------•----------- W U Nature of Repairs or Alterations—Answer when applicable._..__.......................................................................................... -•-•---------••••--•----•-•---•----------------•••-•••-----•-•-•--••-------------•--........-----------•--•-...-----------------------•-•-------------•-•-•----------------------------........-•---•. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the Stafe Environmental Code,,—The and signed further ag s not to place the system in operation until a Certificate of Corn 'ante has bee i ued by e oardbf he Signed -- .. .... ......... .--... ............. Dare ApplicationApproved By ----------- . - ------- ----------------------------------- ---............................... '6"... Date Application Disapproved for the following reasons- ----------------------------------------------------------------------------------------------------------------------------------------- --------------------- -- - ---- -- ------------------ --------------------------------------------------- ---- ---------------------------------------------------------------------------- ----------/<--"--]-.g.......Date PermitNo. ..-. --- -->--. G-- ............................-- Issued ........................................................ Date 333 - 036 ' No... .:., --5 _ Fss ........ �, THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1 !� TOWN OF BARNSTABLE iJ r Appli.ration for Eltnpniin1 Workii Toastrnrtinn Vamit Application is hereby made for a Permit to Construct (L_�or Repair ( ) an Individual Sewage Disposal System at: 1,©T o1& ,82��U)001) L/'-j COmfi � oulb -•--------------__--------............................------......._.....................------. ----•••---......---.--•--.....----•-.•--------.....----•-......----------.............._........-- ocati n- ddress t o r. ............ ............................ Owner Address = /LLS Installer Address Q Type of Building Size Lot..__L6`/_.1/a: -.Sq. feet Dwelling—No. of Bedrooms___....3...............................Expansion Attic ( ) Garbage Grinder (/Lv Other—Type of Building�VQ a YCXA!: No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures .. ��-•-----------•-•---------------------------------------------•-- ------ ..........------------------- W Design Flow.................../�O.................gallons per per-s®xr per dad. Total daily flow......... 330`. ................gallons. WSeptic Tank—Liquid'capacity_62 gallons Length___-- _4. .Width___�....0.._ Diameter.->_..,.�.._. Depth................ x Disposal Trench—No. .................... Width.................... Total Length........ _. Total leaching area............ ft. Seepage Pit No---------- __.._... Diameter-----10......... Depth below inlet.._.._._.�..i....._ Total leaching area..�....._......sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ l Test Pit No. 1_X_. -_..minutes per inch Depth of Test Pit__- ........ Depth to ground water-----Al 0 NFL. ••. Gi,, Test Pit No. 2................minutes per inch Depth of Test Pit............___..•.. Depth to ground water........................ ----• - --------------- ;.... O P , _ ---------------- < < .- ------- Descri Description of Soil_.0._'. -...... � �? ► y /3 ��� x W •-•-----------------------------------------------------------------------------------•-•------------------------------------------------------•-------------------....----------------................ U Nature of Repairs or Alterations—Answer when applicable................................................................................................ -------------------------------------------------------------•----------------------•---------------------------------...-•-----•••-•-••-•----•••••----•-----•-•--••••••-••••--•••••-••••--•--•-•--..... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The ande�signed further agr es not to place the system in operation until a Certificate of Comp*ante has bee is ued bV heoard bf he 'h Signed ...... ...... . ............................. ---------- . ................ ................................... Date Application Approved By -----------C - { /- ---- - - ---------------- -----/, r, " v ................................................................... Date Application Disapproved for the following reafons- ---------- ----- ------ --------- -- --------- ---- -------------------------------------- ------------------------- fi .. ----------------------- ... --.... ------ ...----.......... ..---...------....-..................................................... ..r l > ---------------------------------------- - Date PermitNo. .. l.o... .. ........................... Issued ......................... ......................... .................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE (Cler#if ra e of Contpliance THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed ( ✓ ) or Repaired ( ) by...\7.�1- -_U lSCo�- ------------- ----....--------............---------- Installer at a.r....... _6---------Re,evT.GtJ-U-!).b........ �'-- ------ ��'U M 4 a 6//D - has been installed in accordance with the provisions of TITLE 5 of The State E vironmental Code as described in the application for Disposal Works Construction Permit No. .......Y"...�.�.�..'....5��... ---- dated ........ ,�.-..�.�:.'...�. .... THE ISSUANCE OF THIS CERTIFICATE' SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE . . '--�.I.............. ------- ----------------- Inspector ... ------- ........................................ - -------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 9a S TOWN OF BARNSTABLE No.................. . FEE.....16 d......... Mapann1 Works TnniLrnrtinn rrntt# '�/`T G? l S C U Permission is hereby granted ...••- • -- ----........ to Construct ( �) or Repair ( ) an Individual S�e `rage D al S at No...-4. U•�-•.... ..... LsY Y a U/�/� - / Street /(� as shown on the application for Disposal Works Construction Permit N ._ - ..4�D. Dated...... ............................••.••••-•-•----•-••----•-•-•--••--•--•...••••-•-•••••-•-•--••---......... U DATE............. Board of Health �� t ` ......-'-------------------------------•-• FORM 36508 HOBBS Et WARREN,INC..PUBLISHERS i ,SEr C -rA NY-; 8-�o I So'fo 4�S AQ L I'Dl7?oSAL: ( ;(oat �,�L�Q,_STprJ�:� .. (e f��l'RU,O� �• { :SI'DO WU AQUA l54'SF I: 4 , ;BoTToM AQ� 1-s4 s F �v M vv\Q a c )1 t=> TOTAL`t16N _ � . -rorAL DAI L ox- T�E¢�Dc.A71oN. v C� V / ! Rauh ' Pf.TE R ;. Ib.24W.9 �' •Plo. 29733 z �`� � •r'�;ter?t� �..-r OLt V. .,—gin--- GQL; IN►1 $I S r►ir g ' (odo iu✓ eo'1 TANS. (.�Au} -- 10 - wl.tr z: PE' -S � ..Aug I. 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