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HomeMy WebLinkAbout0121 HAMSTEAD LANE - Health � MSOTEAb LANE, BARNS Yfi:3L A - , r do .° yr .. - .. k ., ,tt x •. :, ,� c , r , I r n L^ „ yr• � 4: ._ > I ..... w i•a• r y d.. n, • 1 ti r ., G - 355-Doa -dos' Commonwealth of Massachusetts Title 5 Official Inspection Form ; i= Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Id- Property po Address a Owner Owner's Name _ information is _V••G 1 A �_ �3/ Ord. required for every u page. City/Town � I State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When When A. Ins ector In o ation filling out forms p on the computer, / / f use only the tab key move your Name of Inspector ,// v cursor- not -� f� use the return N an Compy ame ( C� key. ffod 00 Company Address M City/To � U o / go State / �O ^� Zip Code rear / `� �-lf' -v�J Telephone Numbe License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above-the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that:>Pa t 1. sses r 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails A.[do _ Inspector' Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 1 or 18 Commonwealth of Massachusetts Title 5 Official Inspection Form - �a Subsurfac e Sewage Disposal Sy stem Form -Not for Voluntary Assessments uPro Lperty Address � Owner Owner's Name `T rro la vh information is J /�f a required for every U��9 �H�CV /_ , /J page. City/Town State Zip Code Date of In pecti n C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System P es: 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: 2) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7126/M18 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth wea th of Massachusetts Title .5 Official Inspection Form jSubsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address r'o /A Y'J-O Owner Owner's Name / / n information is (,t ol�A U4 6 G�required for every page. City/Town State Zip Code :Da:t:,of Inspe ion C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed _ ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303 1 b that the system is not functioning in a manner which will protect public health OO Y 9 P safety and the environment: III t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form I. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �t"7 S40-wCj Property Address L v7 Owner Owner's Name information is ci�l qrequired for every [[Gii page. City/Town State Zip Code Date of Ins4ectiont C. Inspection Summary (cost.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c.,Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System F rm -Not for Voluntary Assessments 1 u Property Address / I Jr0 I G't(r10 Owner Owner's Name nn l 14 �-t l y, information required forlevery yd � page, City/Town State Zip Code Date of Ins ction C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ E2,,-�Liquid depth in cesspool is less than 6" below invert or available volume is less than '/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: ❑ Rr"" Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ �d' Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ P-� 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 2000 gpd- /10,000 gpd. ❑ .Lj�./ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section C.4. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Offidai Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts �. Title 5 official Inspection Form Subsurface Sewage Disposal System Fo m -Not for Voluntary Assessments l a Property Address l/'0talAlo Owner Owner's Name LVC)4 information is (A(/{/j M CA 0.(4 IV- page. f� required for every City/Town State Zip Code Date of In ecti C. Inspection Summary (cant.) If you have answered"yes°to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no" for each of the following for a/!inspections: Yes r ❑ P ping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? ❑ he 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.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal Syste Form - t for Voluntary Assessments o� �r S Property Address Owner Owners Name information is required for every (I!t� l7 ti pt 1.4 t� page. City/Town State Zip Code Date of Insp ctio D. System Information 1. Residential Flow Conditions: 3 Number of bedrooms (design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Description: / `Soo G� /10� a+c �as 0 4/ / 4--oro M 6-//,, Number of current residents: pvl lay/ . Does residence have a garbage grinder? S S d eSt wd e/ es ❑ No c7r ,.- Does residence have a water treatment unit? ❑ Yes to — If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes No information in this report.) Laundry system inspected? ❑ Yes No Seasonal use? ❑ Yes ;000No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? Yes ET000NO Last date of to occupancy: f Date t5insp.doc•rev.7126l2018 Tide 5 official Inspection Form:Subsurface sewage Disposal System-Page 7 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage/Disposal System For -Not for Voluntary Assessments Property Address / Owner Owner's Name information is C(AM�a aN� J 7�— Anspe �J�required for every Y i P (yj�(J page. City/Town State Zip Code Date on D. System Information Y cost. 2. Commerciallindustrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15:203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: t Source of information: Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: — t5insp.doc-rev.726/2018 Tide 5 Official Inspection Form:Subsurface Sev age Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -No4fr Voluntary Assessments u- Property Address �/'oil4 v7o Owner Owner's Nam information is �l�a GJA4required for every Name CDC page. City/Town Site Zip Code Date of Inspecton D. System Information (cont.) 4. Type of Syst Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age off 111 c mponents, dat inst lied (if known)and source of information: l/ /� — 'TOW Were sewage odors detected when arriving at the site? ❑ Yes ff No 5. Building Sewer(locate on site plan): Depth below grade: f eet Material of constructi��4OPVC ❑cast iron I ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints,venting, evidence of leakage, etc.): t5insp.doc•rev.726/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal 8yslem•Page 9 of 18 Commonwealth of Massachusetts e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner 1 Owner's Name information is ` re i qu red for every �a�� � Qa-G3 A page. City/Town State Zip Code Date of In ctio D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: feet Material o onstruction: oncrete ❑ metal ❑fiber lass g ❑.polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach.a copy of certifi e) Yes ❑ No Dimensions: Sludge depth: 0z Distance from top of sludge to bottom of outlet tee or baffle. 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 How were dimensions determined? /{ Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): :°e;' r ad CDC , o� -. t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments se Property Address ro &elo Owner Owner's Name information is required for every �L4 01M A 0,164 t — page. City[Town State Zip Code Date of In ecti n D. System Information (cost.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Scum thickness --- Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day tsinsp.00c•rev.126/2018 Tide 5 Official Inspection Forth:Subsurface Sewage Disposal system•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v'i4ec4- Property Address Owner Owner's Name A information is � .�y (i required for every �v (� f�u t page. City/Town State Zip Code Date of In pecti n D. System Information (cost.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): �— Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): b t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System orm -Not for Voluntary Assessments Property Address G-fro l ct VV o Owner owner's Name/' information is / �A 'n required for every l.i v � (.7w'�.t t page. City/Town State Zip Code Date of Ins ection D. System Information (cost.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): 1 * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: leaching pits ucz number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: overflow cesspool number: ❑ innovative/alternative system Type/name of technology: ---— t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 13 of 18 Commonwealth of Massachusetts P Title 5 Official Inspection Form Subsurface Sewage Disposal System Fo -Not for Voluntary Assessments f" /off- Property Address Owner Owners Name u Of A G-AA �� co information is required for every page. City/Town State Zip Code Date of I specti n D. System Information (cont.) 11. Soil Absorption System (SAS)(cont.) Comments (note condition of soil,signs of hydraulic failure, level of.ponding, damp soil, condition of vegetation, etc.): P'0,A ,I --- Qt 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction — Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts P Title 5 official Inspection Form 11. Subsur face Sewage Disposal gSystem Form -Not for Voluntary Assessments Property Address , f Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Inspectio D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: - — Dimensions Depth of solids — Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Nnsp.doc•rev.7/26/2018 Title 5 Official Inspection Forma Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts �d . Title 5 Officia l a Ins pection Fo rm orm �b Subsurface Sewage Disposal System Form -Not for Voluntary Assessments /01 AG Property Address ' Owner Owners Name information isC<A required for every page. City/Town State Zip Code Date of Insp ction D. System Information (cunt.) 14. Sketch Of Sewage Disposal System.- Provide anew of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: Z�and-sketch in the area below ❑ drawing attached separately ILI f OC S 46 �c vv — CS t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal S tem Form -Not for Voluntary Assessments Property Address Owner Owners Name cl Ica information is k� required for every �u(M(/h ;l C4iG page. City/Town State Zip Code Date of Inspec ion D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells / �- Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date — ❑ bserved site (abutting`property/observation hole within 150 feet of SAS) Checked with I al Board of Health- explain: � S lcl�tSsf f�o% ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe}ow established the high gf°und water elevation: 10i 01 LA S !( Cc, w✓4 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 r Commonwealth of Massachusetts P Title 5 Official Inspection Form I. Subsurface Sewage Disposal Sy e Form -Not for Voluntary Assessments Property Address / Owner Owner's Name /� information is / 4�07G n oc // required for every C� �.t page. City/Town State Zip Code Date of In ection E. Report Completeness Checklist Complete a pplicable sections of this form inclusive of: A. Inspector Information: Complete all fields in this section. ;E9' B. Ce ification: Signed & Dated and 1, 2, 3, or 4 checked C.'Inspection Summary: P rY 1, 2, 3, or 5 completed as appropriate 4 (F ' re Criteria)and 6 (Checklist)completed D. System Information: For 8:Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included I.Sinsp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System Page 18 of 18 n4 wP - 35 5s TROY WILLIAMS A ,`i SEPTIC INSPECTIONS dvo�; Certified by MA Department of Environmental Protection oFe 99 (505) 385-1300 19 Hummel Drive �o�t South Dennis, MA 02660 _ COPY COMMONWEALTH.OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: " S L.Qn a. Name of Owner P" u / v 0 C.1- Address of Owner- 1 oZ I Date of Inspection: 1/ I U /9 y Yo-r r o (,/ a. O.Z 6 7S Name of Inspector:(Please Print) Troy Williams 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: Troy Wliliams Se tic Inspections Mailing Address: 19 Hummel Drive, So. Dennis, MA 02660 Telephone Number: (508) 385-1300 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails Irupecto(s Signaturei1 oz. 1 Date: /!//C) The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable, and the approving authority. NOTES AND COMMENTS Although system meets the minimum requirements set forth by the Massachusetts Department of Environmental Protection,certification is not to be construed as a guarantee of future working condition of system,piping or components. This inspection represents the conditions of the system on the Date of Inspection noted above. revi cPri 4 /-) /Qo SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(corrtirwed) Property Address: Owner: 121 Hamstead Lane, Cummaquid,MA Date of kupection: Paul&Linda Dunphy November 10, 1999 NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep/ SITE EXAM Slope �/ Surface water Check Cellar Shallow wells Estimated Depth to Groundwater'�0o`Feet Please indicate all the methods used to determine High Groundwater Elevation: V Obtained from Design Plans on record /Observed Site iAbutting property, observation hole, basement sump etc.) I✓ Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators,installers I/Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) /SC A � !tea v �..� f,,,u.�-�-✓ � (.�,� a-�i"o�, , revised 9/2/98 Page 11 of 11 Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: 121 Hamstead Lane,Cummaquid,MA Paul&Linda Dunphy November 10, 1999 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 8 3r.9 ( revised 9/2/98 Page 10ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property A(kress: Owner: 121 Hamstead Lane, Cummaquid,MA Data of 1pection: PPa�ll u�&Linda Dunphy S15 SOIL ABSORPTION 'Off A�Q'_P99 (locate on site plan, if possible; excavation not required, location may be approximated by non-intrusive methods) If not located,explain: Type: leaching pits, number: / ��G L cc�c S leaching chambers,number:_ leaching galleries,number:_ leaching trenches,number,length: leaching fields, number, dimensions: overflow cesspool,number:_ Alternative system: Name of Technology: Comments: (note condition of soil,signs of hydr ulic failure,level of pond* damp soil, condition of vegetation, etc.) vlz � o7 ru .. l : � .iv. t. J .c..+Y+) N .� 0.j Lilt✓L CESSPOOLS:�[ (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revised 9/2/98 Page 9ofII SUBSURFACE SEWAG E DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: 121 Hamstead Lane, Cummaquid,MA Dane of Inspection: Paul&Linda Dunphy November 10, 1999 k TIGHT OR HOLDING TANK: N/q(Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order: Yes No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX:V (locate on site plan) Depth of liquid level above outlet invert: Comments: (n e.lf level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box;etc.) o- �.� O,� S l I � Gs�r✓Z o �/P � t o G✓ cl,�.,c.-c �M f 4 G p H / �Y � a..-c. �'t U 1� t,/L✓L .O rr{C �r f- � -�- '�7Grf.e._ 27 PUMP CHAMBER:__LV//9 (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.) revised 9/2/98 Page 8ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM WFORMAnON(cortfinued) Property Address: Owner: 121 Hamstead Lane,Cummaquid,MA Date of Inspection: Paul&Linda Dunphy BUILDING SEWER: November 10, 1999 (Locate on site plan) Depth below grade: /8'/} Material of construction:_cast iron Z40 PVC_other(explain) Distance from private water supply well or suction line Diameter Comments:(condition o�joints, venting, evidence of leakage,etc.) i e✓. "'A C.f e wr et} 7ti✓u.e_. c:�74 SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction:Zoncrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age_ ls.age confirmed by Certificate of Compliance_(Yes/No) Dimensions:_ Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle:�l) Scum thickness: ALO /_ Distance from top of scum to top of outlet tee of baffle:YV S L✓I r Distance from bottom of scum to bottom of outlet tee or baffle:n/o S c ✓�' How dimensions were determined: Comments: (recommendation for pumping,condition of inlet ao outlet tees or baffles,depth of liquid level in relation to outlet invert,structur"tegrity, evidence of leaks e,etc.) F V L %c r r+ It air,dt of /c 1 e S " �f+J ra CK., C ex- � 1 4i 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: (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) revised 9/2/98 Page 7orii SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: 121 Hamstead Lane, Cummaquid,MA Date of Inspection; Paul&Linda Dunphy RESIDENTIAL: November 10, 1999 FLOW CONDITIONS Design flow: /J& g.p,d./bedroom. Number of bedrooms(design): 3 Number of bedrooms (actual):3 Total DESIGN flow 3b W I+i: g�r6w5lour ptwN Number of current residents: Garbage grinder(yes or no):=LES ��cs tic .( 41 Laundry(separate system) (yes or no):NO; If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use(yes or no):_2VO p Water meter readings,if available(last two year's usage (gpd): 26) =IO �Da U �VOU 9 Sump Pump(yes or no):_�o 7 Last date of occupancy: DCc.,��; COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow:_ apd ( Based on 15.203) Basis of design flow Grease trap present:(yes or no)_ Industrial Waste Holding Tank present: (yes or no)— Non-sanitary waste discharged to the Title 5 system: (yes or no) Water meter readings,if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of I formation: �r i N System pumped as part of inspection. (yes or no)_ Vo If yes, volume pumped: gallons 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). I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROMMATE AGE of all components,date installed Af known)and source of information: Sewage odors detected when arriving at the site: (yes or no) NO revised 9/2/98 Page 6or11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 121 Hamstead Lane, Cummaquid,MA Owner: Date of Paul&Linda Dunphy November 10, 1999 Check if the following have been done: You must indicate either "Yes".or "No" as to each of the following: Yes, No . t _ Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped-for-art least two weeks and-the system has been-receiving ITormal 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. The site was inspected for signs of breakout. ►L _ 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, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum. / The size and location of the Soil Absorption System on the site has been determined based on: Existing information. For example, Plan at 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! [15.302(3)(b)] The facility owner(and occupants,if different from owner) were.provided with information on tha.propermaintanauce of Subsurface Disposal Systems. revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 121 Hamstead Lane,Cummaquid,MA Property Address:O W f 1ef Paul&Linda Dunphy November 10, 1999 Date of I+Lspection: D. SYSTEM FAILS: IVIA You must indicate either 'Yes" or "No" to each of the following: have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due-to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less-than 100 feet but greater than 60 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 FAILS: NI/9 You must indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area=IWPA)or a mapped Zone If of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4ofII I - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 121 Hamstead Lane, Cummaquid,MA Owner: Paul&Linda Dunphy Date of Inspection: November 10, 1999 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N//g Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 11 SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. Z) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic-tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER I revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: 121 Hamstead Lane, Cummaquid,MA Date of 1pq- ° : Paul&Linda Dunphy INSPECTION SUMMARYOVeC ek1OA 19B9 C, or D; A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES:)V//; One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes,no,or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20) years prior to the date of the inspection;or the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level.observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed R. . revised 9/2/98 Page 2ofII 3 50* TROY WILLIAMS SEPTIC INSPECTIONS tiro �F 'A M / Certified by MA Department of Environmental Protection T° 3 (508) 385-1300 19 Hummel Drive South Dennis, MA 02660 ®, Fa�lyD Tgell'99) 0� F 1.0 Commonweafth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection WIINam F.Wald Govwnor Trudy Cox* Argeo Paul Celluccl .s.ratsy LL Govwnor Davld B.Struhs Convnksl"r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A _ CERTIFICATION � Property Address: Id 1 14 c`"' S 2 w c� L h. C U N r n n Y Address of Owner. Cj V y 144 c/ �o Date of Inspectbn: jj / (, �y ] (If different) l Name of Impecto o y (.W ; I 1 Company Name,Address add Telephone Number, CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: �G raases Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspectoea Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: �I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: /Vl 4 One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes, no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If"not determined",explain why not) The septic tank is metal,cracked, structurally unsound,shows substantial infiltration or exfiltration,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11/03/95) t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A 1 ' / CERTIFICATION (continued) Property Addresx of t 7 '''^ s L Owner. v Date of Inspection: /a6 B]SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:N/4 Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY.AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a . surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. 3) OTHER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: /a / J Oner. "`a w s Ar—e& c14 L.E., Date of Inspection: M u 4-6 D] SYSTEM FAILS: I ha"determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to failure. determine what will be necessary to correct the Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. — Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. — Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. — Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped — Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. — Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. — Any portion of a cesspool or privy is within a Zone I of a public well. — Any portion of a cesspool or privy is within 50 feet of a private water supply well. — Any portion of a cesspool or privy is less than 100 feet but greater than 50 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. El LARGE SYSTEM FAILS: /VII-1 The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: — the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 ChIR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECHUST Property Address: / 2 ► /4, Owner. M v--o Date of Inspection: Check if the following have been done: "Pumping information was requested of the owner,occupant, and 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 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 , The site was inspected for signs of breakout. ZAll system components, excluding the Soil Absorption System, have been located on the site. _ZThe septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of ba®es or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of a-cum. 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. / The facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ll SYSTEM INFORMATION // Property Address: f cC Owner. A,, Date of Inspection: /V r u RESIDENTIAL- FLOW CONDITIONS Design flow: 3_. y eallons Number of bedrooms: 9 Number of current residents: Garbage grinder(yes or no):__?6 S Laundry connected to system(yes or no):,_-1L-17 S - Seasonal use(yes or no):�/U Water meter readings, if available: 96 Last date of occupancy: G�. , e e} COMMERCIAL INDUSTRIAL A114 Type of establishment: Design flow:�allons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yea or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no) Water meter readings, if available: Last date of occupancy: OTHER (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: ? L /Y- - 1 G✓cH In G r A S 4. G � U.� ( ,". � , v-rvl SYztem Pumped iis part of inspection: (yes or no)J/O If yes, volume pumped: gallons Reason for pumping. TYPE F SYSTEM Sept tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records, if any) Other(explain) MAPPR OXIMATE AGE of all components, date installed (if known) and source of information: I c r/l Sewage odors detected when arriving at the site: (yes or no) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Address: Owner. U 1 Date of Inspection: a 7�G /� 7 • SEPTIC TANK: (locate on site plan) Depth below grade. � Material of construction: Vconcrete_metal_FRP--other(explain) Dimensions: 9 ' x l/ x 6 /rS O O Sludge deptlL 3�� Distance from top of sludge to bottom of outlet tee or baffle:-r,2 _7 Scum thickness• 6 Distance from top of scum to top of outlet tee or baffle: 6 % Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) P U C• 1 mac,i — i, l �L c�,(5►�� . - T �e c✓• Ada /[ A-f' c�c L✓t T/6+ ✓-, d( ��[ h/o✓lL��,I` Kr- i'tn u- ry •� i T" �.✓G � LnY�l�G/ 1�tlA1c Oi✓!nt✓ C-- plc i� 0.� cif S C c :► ��cu( '!VLi YUr �Li � tr i� ct� ✓ho��L' GREASE TRAP•.-(//.g —Se- c,* o (locate on site plan) Depth below grade: Material of construction: _concrete_metal_FRP _other(ezplain) 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: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner. ,fin Date of Inspection: TIGHT OR HOLDING TANK:///� (locate on site plan) Depth below grade: Material of construction:_concrete_metal_FRP—other(explain) - Dimensions: Capacity:- mllons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX._V (locate on site plan) Depth of liquid level above outlet invert: C0 C Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) y r.-cA I L/f^c ✓ r [- w o ✓h i �. 5 G �� �.c✓ w G 5+✓ i S •�ri dj I fj' o,, 4T Dflr.f T�oc.J O�'41 - S 7 PUMP CHAMBER:_��� (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address[ �o� � �.rr, S �c L �.. Owner. /1"4 U Date of Inspeotion: 02 /-26 �y7 SOIL ABSORPTION SYSTEM (locate an site plan, if possible;excavation not required, but may he approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: o� L� 'L e cL c leeching chambers,number._ leaching galleries, number. leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Cents: (note condition of soil signs of hydraulic failure, level of pon • , condition of vegetation,etc.) . o ; C.J c` S � ll'-fi U ti s c CESSPOOLS: A 11'9 (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(osspool must be pumped as pert of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate on site plan) Materials of construction: Depth of solids: tensions: i Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 11/03/95) g SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 1 /� SYSTEM INFORMATION (continued) Property Address: / a !"TU A- .S T/ c c..eA � h Owner: Date of Inspection: M " SKETCH OF SEWAGE DISPOSAL SYSTEM: indude ties to at least two permanent references landmarks or benchmarks locate all wells within 100' G 36 3 15 vo 130 X L101t-s tb DEPTH TO GROUNDWATER Depth to groundwater: feet adjusted high groundwater level_ method /of determination or approximation: L I a / ,O l /�✓ S A w / {ter o cJ La.T L�/ TO/ L J N 1�k GA- 9 , . . = TOWN OF BARNSTABLEC�' LOCATION I 14� S 1 c a SEWAGE # / ' VILLAO- C ASSESSOR'S MAP & LOTMI DN OT INSTALLER'S NAME&PHONE NO. • 5 s ' '� . SEPTIC TANK CAPACITY n S y y ` LEACHING FACILITY: (type) (size) NO.OF BEDROOMS 9 BUILDER OR OWNER AA a -�v PERMIT DATE: N/Z) Z COMPLIANCE DATE: S �1 ,- Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist 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 ��{�. :rr'?. }. f . . 21 �� l� � H, 3� 3'y 3'.Y 6 TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE ASSESSOR'S MAP & LOT Iff I� INSTALLER'S NAME PHONE NO, SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER ow w k BUILDER OR OWNER (�y y- AA u-ro DATE PERMIT ISSUED: �YA 7/914 DATE COMPLIANCE ISSUED; 5' / 9� VARIANCE GRANTED: Yes No x e M 36 3� of ASSESSORS MAP NO: PARCEL NO: FEB THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH • TOWN OF BARNSTABLE C - 'Appliration for BWvviial Works TaMitrnrt' r Application is hereby made for a Permit to Construct (�) or Repair ( ) an Individual Sewage Disposal System at: f Location-Address or Lot No. .................................................................................................. -•---•••••-•...................................................................................... caner Address a ► c,. s 1__._...... o ...gAgak 4...------- --' °........ $4 Installer Address Type of Building may, Size Lot__ _?:1_ d`....Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder (x) `4 Other—T e of Building No. of persons............................ Showers — Cafeteria 04 Other fixtures ........................................................ w Design Flow............... _��___......_.----------gallons per person per day. Total da-i-ly flow...............��- 4...._..._..dl o�ns-- 1 WSeptic Tank—Liquid*ca acit 150—.�llons Len th_�i '�-t Width-�1- -{- Diameter ------------- Depth-------. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area ........sq. ft. Seepage Pit No.......... _._�.... Diameter.._.__l�P_..... Depth below inlet Total leaching area.+bPa .3Zsq. ft. Z Other Distribution box (X) Dosin tank ( ) „�. qq '"' Percolation Test Results Performed by._: ....�. 9.5�_,__ Date....-�.._ —J. ,.a Test Pit No. 1....... '___.minutes per inch Depth of Test Pit____ Depth.to:ground water_____i�_Q:l�l,�..,__. 44 Test Pit No. 2........4r.__minutes per inch Depth of Test Pit------ Depth to ground water------Npf`1C__- P4 ---------1 ---------------tt•••-••••--••••••••-••••-......-•-•--•--••--•--•--- t -------------------•-tt......----- O Descri tion of Soil_ - j..�Q_d_ _�t! _pit P �_t:!�.. :A$.... �s��D KEVU1k x tl _ « �.� w 't ------S-A_1. p ._�J.�--f"t4 ------------------ UNature of Repairs or Alterations—Answer when applicable__.___---_-•................................................................................... •-••-•-•-•-•-•----••---•-•--._...•••••-••--••---...-•-•--•-•-------•-----•-•••••••-•-•-----------•---••-••-•--•-••••••----------••••--•••-•••-•••---•-•-----••---•••••-•••-••-....••--•-•---•--•--•-•••• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by t e board of health. Signed jZ„n:v-bA:.J � n ' Date Application Approved By ----------------� �------------------------- ---..-1;�7-•Date--.- --�-� Application Disapproved for the following reasons: ---- --------------------...............................................................-------------------------------------- ____ .........................----....................—............----------_ .--.................-.................---............------------... ........................................ Date Issued Permit No. ...... (�3 Date ass THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Disposal Works Tn n.rtion rr Application is hereby made for a Permit to Construct (�) or Repair ( ) an Individual Sewage Disposal System at: Location-Atidres°s or Lot No. ......................_--........................................................................ --------•-...._.............•.. Owner Address Installer Address Type of Building Size 7 .1...Sq. feet aDwelling—No. of Bedrooms_____________________________---------------Expansion Attic ( ) Garbage Grinder (X) p4 Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) P4Other fixtures .............-•----------•---------------------------•------------------- -----------------•-------------•-•----------------------------------------- d W Design Flow................C__�J__.-..-.__.__....-_.gallons per person per day. Total daily flow.._......._.._. a .............gallons. ( it +1+ I t WSeptic Tank—Liquid capacity.) .gallons Length-0..-ta.. Width_C-9._ Diameter________________ Depth_S___-9_. x Disposal Trench—No..................... Width.................... Total Leilgth......._......p----- Total leaching area_...................sq. ft. Seepage Pit No..........7_e Diameter......1<�hl...... Depth below inlet....... Total leaching area.+,/,)_9.e,_3%6q. ft. Z Other Distribution box Dosing tank ( ) �. � � Percolation Test Results Performed by..__ _( � -___ .__._1 c..I.�.�=.`1._.. Date....... 0.4 Test Pit No. I....I.4-_._minutes per inch Depth of Test Pit..... ''__ Depth to ground water.._..�� 44 Test Pit No. 2......._.,'�-..minutes per inch Depth of Test Pit------ate/ .k.N.Depth to ground water._....1Jo_RI_ .. ...... ................. � �. = � .. i------- ......t.......................................• O t 1 � L'�t�R li lw� ���escr Description of Soil--' � .._ .�,.- -:�•---- 10� . � ► _ �C:fly.7 - `\ 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 undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed --------t ,w.► � � 1 /X7`/�.2------- te Application Approved By ------- !.. = Application Disapproved for the following reasons- ----------------------------------------..........--- -----------------------------. --------------...........----- ------- I ------------------- ------------------------------g----------------------------------------------------------------------------------......................--------------------------------------------- ---------------------------------------- PermitNo. ----- ---------------------------- f Issued ------------------------a---------------------------Date-- -- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH F. TOWN OF BARNSTABLE (frdifira e of Conty1i tnce > THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( ) b _ - -----------------------------alle---------------------------------------------------------------------------------------------------------------------------- -Q—------ Instr ------- - --i-.. has been installed in accordance with the provisions oPWLof The State Environmental Code as described in the application for Disposal Works Construction Permit No. -..-..gam....,---- -- ---------- dated ..-"-.""-."...............--.."...........--. 'THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE a&STRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE... s3�------ `,''----� �---------------------------- Inspector - .................................... ----------------- --------..--- -- V 8 i THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No............:•p_---••- FEE.... �r Disposal Works Tonstrurtion Ophrutit Permissionis hereby granted.---.------ `1'--.6-0a_......... ..2C_ .r ......................................................................... to Construct (V) or Repair ( ) an Individual Sewage Disposal System L at No.....................---•p t- L�j............ -.r�Q --..... f ;�� :_ � 11. .* Street as shown on the application for Disposal Works Construction Permit N -\ Dated__________________________________________ .............................. •-------------•--------------.----•--------.-_----------- `J Boa DATE............... _-_ _7. ................................ rd of Health FORM 36508 HOBBS 6 WARREN,INC..PUBLISHERS ©� "? DESIGN CALCULATIONS By SEPTIC SYSTEM INVERT ELEVATIONS REvtaiotts —' CROSS— SECTION PROPOSED TOP DIST. BOX IN I-- �!_ FORA BEDROOM HOUSE WITH l , GARBAGE DISPOSAL ,: -- r _,- _.._-_._ • OF FOUNDATION DIST. 80X OUT ' SEPTIC TANK ' '`t" X s , SEPTIC TANK IN LEACHING SYSTEM IN ti ' �`'�' x - 2 >r�N�S USE A . 2�2 GALLON TANK :r' i;. LEACHING P/T/USING 7 -6'X `'� 'P/T W/ 2. 'STONE - -- -- — _. AREA ^ '�/tt , . "', t � , �- ----_ S/DEWALL 1 HEIGHT X 2 X TT X RADIUS -- .17 X2 X IT FLOW 4-7 -:;, 1(` .�,. ( `S.F. X t GPD/l ��07 -��'GPD BOTTOM.' TT(RADIUS)2 SEPTIC TANK 0 U T '--__ • • LOCUS MAP EXIT �1, �� LEACHING SYSTEM BOTTOM el 2r S.lc X_�'� GPD/1 : ?.`k GPD TOTAL 1 i _ fir '� GPO � DESIGN FLOW t _ _�"� ... GPD Z Pitch 1/411 Per Foot (Min.) RESERVE I • v GPD 0 2% GRADE (Min.) 0 tl •r. 11 11 1 it .. Z -3 Min. 2" Min. 2 yg /2 washed stone Q 211Min. r LAID ' � ' t% .: LEVEL 1b M 11 FOR 7 4-0 Liquid o Level DIST. BOX g O f 7 - Pitch 1/811 Per Foot o& (J7 GALLON SEPTIC TANK (Min.) � � W Z Uj 4 Schedule 40 P,V.C. /4"1 /2 Q 0 �` Q Or Equivalent Washed Stone I+ —•1 �+-, ' ••� NOT TO SCALE LEACHING PIT (f) TYPICAL CROSS— SECTION r z W l L Q cc n/ 1 NA NOTES o 0 ELEVATIONS SHOWN ARE IN FEET ABOVEIL I 0 eL,)A t ,, . �.1�� I�7 0 ��� ��`j �, �•�: a,�: !. ti LAAe7 vKG�i n F VO. A Z.0 �?D PAR. �p ! 15 -� /` _ © t' 1 ACCESS COVERS OF THE- SEPTIC SYSTEM j W ARE TO BE W/THIN /2 It OF PROPOSED GRADE. E - THERE /S TO BE ONE FOOT OF GRDUNOCOVER IL ►� �` J� .. to O ' ,tI"p 5, �' \ W A \ r ,�✓ /� OVER THE SEPTIC SYSTEM. O W O CONSTRUCTION OF THE SEPTIC SYSTEM /S TD z U. 1+ ({ C THE STATE SANITARY TARY CODE. U) W kt \ CONFORM TO Lj TTTZE Y, AND THE TOWN OF \' BOARD OF HEALTH REGULATIONS, DESIGN LOADING OF SEPTIC SYSTFM SEPTIC TANK s H- `f='" 5CJ D STRENGTH +i IST. BOX & H - STRENGTH W >` LL LEACHING P/T+H- STRENGTH W (AD _j SOIL TEST DA TA lkJRat �y q c WC © Cc) GJMK�f�- - M � AWN gR,,fi � 5® ,v0 ; G f�k: ° n,aa h,Mav . S,ugSo1L `D-' v a CHECKED __ ..w.;� 1 ,,.:. 1� VAC 1 � +�►I o� '� t-!=` KEY DATE EXISTING ELEVATIONS X r' i � ��� JC"� \ . L51 ► ► `: + ,--► , A11P SCALE EXISTING CONTOURS 1 f (� I W PROPOSED CONTOURS —' -'0'--�-- � ;�� ;�'` t�tk JOB NO. TESTPIT LOCATION �`� ... / +I d ��"" K CATCH BASIN ,A �-Z SHEET -"C I+��, _. WATER FOUND �'�� WATER FOUND, , UTILITY POLE TEST MADE TEST MADE' WITH i ,f,. WITH F.B. I S` GATE AC3ENT,�F-F'��'j; ;, , BOARD OF HEALTHPERC. RATE , LESS THAN „ MINUTE PER INCH DROP OF , SHEETS