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0009 INDIAN HILL ROAD - Health
9 INDIAN HILL, ROAD Barnstable A.- '336 - 055 i i i i i I i Commonwealth of Massa6h6s6tibs. �- Title 5 CJf icial-Ins;pection ,*.Fo x l Subsurface Sewage Disposal:System Form Not for Voluntary Assessments _" 7k 9 Indian Hill Road; �, Property Address h. Robert Murray. r� Owner Owner's Name information is �/ required for every. Cummaquid MA, D2637 03/02/20 page. city/Town State Zip Code Date of Inspection. h , Inspection results must be submitted onthis•forin:_Inspection forms may not be°aftered in any:. way. Please see completeness checklist at the:end of the form; Important: When rms filling out forms A. Inspector information S/ on the computer, use only the tab Mathieu Rebello : key to move your, Name of Inspector, . cursor-do not WK use the return Company Name key.. 30 Norse Rd . Company Address ..South Dennis MA . . 02660, Ciry/Town State Zip Code' 774=722-0271 SI 14140 Telephone Number License Number: B. Certification I certify. that: I am a DEP>approved systemins mpector futl compliance with Section 15.340 of Title 5 (310 CMR 16.000); 1 have personally°inspected-the'sewage disposal system at the,prgperty,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.Afterconducting'thit inspection.I have determined that the system: p 1. as 2. ❑ Conditionally.Passes 3: ❑ Needs Further;Evaluation by the !_Deal Approving Authority. 4. ❑ ,Fails i 031,02/20. Inspectors Signature Date The system.`ins inspector. submit a coPY.-of this inspection report to the Appravmg Authority(Board P 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 DER, 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.atthe time of inspection and under the c9ndi,tions7 of use at that time.This inspection does.not address how the system will perform in the future under the same ordifferent-conditions of use. t5insp Coe•rev.7262018. tine 5.ofticiai Inspection Form.Sub wrfecce Sewage.Disposal system•Page i of 1a Commonwealth of'Nlassachusetts E Title Oicia Inspection tom= Subsurface Sewage DisposaUSystem Foffn "Notfor Volun.th "Assessments 9 Indian Hill Road Property Address Robert Murray Owner Owners Name information is. required for every CummaQ uid AAA 02637. Q3102l20 . - page. City/Town State Zip Code Date of lnspedon C.:Inspection Summary Inspection Summary* Complete 1 ;2;3, or 5 and'"all of.4 and 6: 1 j System Passes ® I;have not found any information which,indicatesthat any'of the failures criteria described in 310 CMR.15.303 or'in 31 Q CMR 15.304 exist. Any failuEe criteria not evaluated:are . :indicated below. Comments 2) System Conditionally Passes: , ❑ One or more system components"as descnbed in the Conditional Pass"section need to be replaced or repaired. The system, upon completion`.of theTeplacement or repair, as approved_by the Board of Health,"will pass: Check the box for.uyes""no" or"not determined''(Y, N;°ND)for the following°statements. If"not determined;"`please explain The septic tank is meth[and over 20 years�old`.or the septic ank.(whether.metafor not) is structurally unsound,exhibits'substantia1 iriflitration or exfiltraition"or tank failure.is imminent. System will pass inspection:ifrthe 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-thanr 20 years'old is available'" : ❑.Y 0 N: ® ND(Explain below) t5insp.doc•rev:7/262018 Tale S:Official lnspedion Fam:.Sub�aiace Sewage:0isposal System Page 2bF 18 Commonwealth of Massachusetts Title 5 Ofl•ici2�:F.I�tspection ��om Subsurface Sewage Disposallystem Form Not for,V6IUntary Rssessments'r.. 9 Indian Hill Road Property Address Robert Murray Owner Owner's Name information is Cumrna uid required for every Q MA 02637 03l02l20 page. City/Town: state. Zip Code Date of Inspection C. Inspection Summary (cont.), 2) System Conditionally Passes_(cont:): ❑ Pump Chamber purnpslalarms not operationoi.,System will pass with Board of Health approval if pumps/alarms are repaired. ElObservation of'sewage backup or break out.orhigh.static.Waterlevel-in the Aistribution box due to broken or obstructed pipes)or due to a broken,"settled or uneven distribution box:System:will pass inspection:if(wiiith:approval[of Board.of Heatth).:... broken pipes) are rep laced ` ❑ Y ..,❑ N . ❑ ND(Explain below): obstruction is,removed ❑ Y ElN- ❑ NfD(Explain below):' distnbution box is leueled ou�eplaced ❑ Y ❑ N '❑ ND(Explain below). The system required-pumping more;than 4 times ayear�due,to broken or obstructedpipe(s); The system will pass inspection if-(with:approval`of the Boardof Health}: broken'pipe(s)are replaced' ❑ Y ❑ N ❑ ND(Explain below): ; ' obstruction ►s removed ❑ Y ❑ N ❑ ND(Explain_below). 3) Further Evaluation is Required by Board of Health. ❑ £onditions 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 310CMR 1&303(1)(b)-that the system is not functioning.in a mannerwhich will protect public health, safety and the environment: t5insp.doc M.,7r26/2018 Title 5 Official Inspection Form Subsurface Sewage,Disposal System•Page 3:of,18 Commonwealth of Massachusetts Title 5 Official Bnsp ction Orm= " Subsurface Sewage Disposal System Form='Not for Voluntary Assessments >: 9 Indian Hill Road Property Address Robert Murray Owner Owner's Name information is Cumrrta ud MH 02637 . 03/02/20 required for every G page. Cirylrown State Zip Code Date:of Inspection C. Inspection Summary ('cont ) ❑` Cess ool or priv is within 50 feet of a suiface)water 0 Cesspool or privy Is within 50feet of-a:bordering vegetated wetland or:a Salt marsh b System will fail uniess the Board of Health{and Pubhc-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 10.0 feet of a surface;water supply or tributary to a'°surfacewater supply.,-* The system has :se tic 'tank and SAS and the SAS'iswithina Zone 1 ofa ublicwater e a ❑ Y p P su pl . P Y "nd h A .i i hin 50 fe of a rivate water:a e is tank:and.SAS,a t e S S s w t et' � The�system:has s.pt p . supply well 0 The system has a septic tank and''SAS and.the SAS isaess 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'perfor. at:a DER certified laboratory,.for fecal coliform bacteria indicates absent'AM the presence Of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no otherfailure criteria are triggered. A copy of the ana{ysis must be attached to this form: c: Other: 4) System Failure Criteria Applicable to-A11 Systems: You must indicate"Yes"'or"No'.'to each:of the folioiaring.:for all'inspections:: NYes No Backup of ewage into facility or system:component due to overloaded of` ® clogged SAS or.cesspool .Discharge or ponding of effluent tathe surface-of the ground or surface waters due to an;overloaded orclogged,SAS or cesspool t5insp;doe rev.712812018- TiBe 6Official Inspection Forth Subsurface Sewage Disposal System Page of 18 Commonwe alth of Mas§achusetts Title 5 Officia Inspcton �® ►t Subsurface Sewage',Olsposal;System Form -Not for Valuntary:Assessments 9 Indian Hill Road Property Address Robert Murray Owner Owner's Name information is mm i Cu a u d', A M `0 7.263 I required for every q 03/02/20 page. City/Town State Zip Code Date of inspection. . C. Inspection' umm arN Cont. 4) System Failure.Criteria Applicable to Ali Systems: (cont:)' Yes No Staticli uid evel inthe distribution box above outlet invert due to an overloaded oaded or.clogged SAS or cesspool P. Liquid depth in.cesspool is less than 6"below invert or'avaiiatle volume is:less than:Y2 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. El Any portion of a cesspool or privy is within a Zone.1 of a publicwater supply well. ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ET . Any:portion'of a cesspool°or:privy is less than 100 feet but greater than 50 feet from a private water supply wel(with no acceptable water quality analysis. [This ~+ system-passes if`the well water.analysis, performed at a DEP certified laboratorysfor 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 otherfailure criteria are triggered.A copy ofahe analysis and chain of custody must be-attached to this form.] Y .The system Is a cesspool,serving a facility with:a design flowof 2000 gpd ®. 10;000 gpd. The system fails. I have,determned that one:or more of the above failure criteria exist as described in 310'CMR 15.:. therefore the system fails.The ` system owner should contact the Board:,of.Health to determine what will be necessary't0 Correct the failure-: 5) . Large Systems To be considered a large system;the systeitn mustserve 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 imSection C.4. Yes No.; ❑'. ❑ the.system'is within 400 feet of:a.suifa' dunking water supply. 0 ❑ the.system is within 200 feet of a tributary to a surface drinking water supply the system is located in.a.nitrocien sensitive area(:Interim Wellhead Protection Area:—IWPA)or.a<mapped Zone I of`a public water supply well 15inspAoc•rev.7t262018 Title 5 Offiaal inspection Forme Subsurface:Sewage Disposal System Page 5'of 18 . Commonwealth of Massachusetts 0 `Title 5 O icia`i Inspection Fornn Subsurface Sewage Disposal-System Form-Not-for bIu' ry nta ..ssessrnents°.. 9 Indian Hill Road Property Address Robert Murray Owner Owner's Name information is Cumma uid required for every G . MAr 02637 03/02/20 page. CityjTown' state Zip.Code Date of Inspection C. Inspection Summary. (001110 if you have answered°yes.to any=question in Section 0.5 the'system is considered.a significant threat, or answered"yes"; to'any tuestoon-in,Section CA abov6lhe large system has failed.The owneror operator of any large,system considered a significantahreat under Section C.5 or failed under Section C.4 shall upgrade the system in accordance'with 310 GMR:15.304. The system owner should contact the appropnate.rea onal+'gffice of.the Department 6. :You must indicate"yes"or"no"for each of'the following for all inspections: Yes. No Pumping informatlon'was provided by the owner,occupant, or Board of Health Were:any of-the system components pumped out In the previous two weeks? Has the system received normal flows in the preylous two week period? ... Have, arge vo'iumesofwater beenintroduced to fhe system recently or.as part of this inspection? .Were,as built plans of the system obtained and:examined?(If.they were not ®`Y available note as.NIA) ® ❑ V 801he facility or dwelling inspected fors igns ofsewage"back up? �, Was the siteinspected 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 Ihe'condition'of the baffles°or tees, material of construction, dimensions,.lepth;of liquid; depth of sludge and depth of scum? a ® 1`Was"the facility owner(and occupants if:different fror owner)-provided With information.,on the proper maintenance of'subsurface sewage disposal systems? °The size and;iocation'of the Soil Absorption'System'(SAS)on the site has been;determined based"on< = , - 0 Existing info'",mation;.:For example;-a plan at the Board of Health. � Z ':Determined in the field{if any of the failure criteria related"to Part C is at issue :appproximation of distance is unacceptable)[310 CMR 15.302(5)1 tSinsP.doc rev:7I26/201e'. This S,Otfiaal lnspeelien,Form:Subsudece Sewage Disposal System Page 6"of 18 Commonweaith of Massachusetts Title 5 Official 8n spectio o'rrv� ' Subsurface Sewage Disposat-System Form NotlorVoluntaryAssessments; 9 Indian Hill Road Property Address. Robert Murray Owner Owner's Name- information is require for every Cumma uitl MA 02637 03/02/20 page. CitylTown. state Zip Code Date of.lnspedion D. System Information 1. Residential Flow Conditions. Number of bedrooms(design).. 3 ` Number of bedrooms(actual):. 3 DESIGN,flow based.on 310 CMR 15 203 or exarnble:110 gpd x#of bedrooms): 330 Description: 1000 gallon septictank,d-box, 2.leach chambers 500 gallon Number.of current'residents. 2` Does:residence have a garbage"grinder? ❑ Yes_ ®':.No Does residence have a water treatment;unit� ❑ Yes Z No If yes;discharges to: ` ;. Is laundry on a separate sewage'systern?(Include laundry system inspection inforrntation in this report.) ElYes ® .No Laundry system inspected? ❑"Yes .® "No " Seasonal use? ElYes No' Water meter readings,.if ayailable: last 2 9 (9P ))" ears usa e': d 86 gpd j Detail: 2019-30,000 gallons 201.8=33,000 gallons p P p Sum um ? ❑ Yes. No Lastdate of occu current . panc y :. Date;. . N t5insp.doc•"rev.7/2UMS Title 5 Official hspedon form:Subsurface Sewage Disposal system Page 7'of IS - Commonwealth of Massachusetts Title 5 Official., Inspection. F ' Subsurface Sewage Disposal.System Form-Not for'Voluntary'Assessments 9 Indian Hill Road PropertyAddress r o e P Robert Murray: _ Owner Owner's.Name info rmation i at on I Cumma uid required for every 4 MA 02637 OWN' page.. Citylrown: state Zip Code Date of Inspection.. D. System.I nformation cont 2. Commerciallindustdal Flow Conditions. .' T YPe of Establishment:_ NIA . Design flow(based on 310 CMR 15.203). N/A Gallons per.Bay(gpd) Basis of design flow(seats/persons/sq.ft, etc) N/A Grease trap present? ❑ Yes No Water treatment unit present ❑. Yes, 2. NO N/A If yes,,discharges to: : . Industrial waste hoiding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the""Title 5 system? ❑ Yes ❑ No Water meter readings,'if available:; N/A, Last date of occupancy/use N/A Date Other(describe below). : NIA 3. Pumping Records: Source of information pumped January 2020 Was system pumped as part of the inspection'?-; ❑ Yes Z No If yes;volume pumped gallons Hovr was quantity pumped;determined? Reason for pumping t5insp.doc-'rev.7/2612018� Tide 5 Offidal Inspection Form.Subsurface:Sewage DisposaLSystem•Page S'of 18 Commonwealth of Massachusetts Title 5 OfficiatfritOectidl Form, Subsurface Sewage Disposal;`System:Form.-:Notfor Voluntary-Assessments 9 Indian Hill Road Property Address. Robert Murray,. Owner Owner's Name . information ie Cumma uid MA . 02637 03/02/20 required for every G page. Cityaown : State Zip Code. Date oEanspection D. System Information cont. 4. Type.of System:. w. ® Septic tank; distribution box soil;absorption tem ❑ Sin a cess col 9 p ❑ Overflow cesspool Privy r a h r f n Shared system (yes-or no if es ttac rev'iotis ins ection reco ds � a ❑ Innovative/Alternative technology. Attach a-copy of`the current'operation:_and maintenance contract(to be obtainedfrom:system owner),and a copy of latest inspection oft UA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval.: ❑ Other(describe): Approximate age of all components, date installed(if known)andsource.of information: oridihal 1000 gallon tank', H2O dbox and 2 H10"leach ehambo s installed 6il6/l6' Were:sewage odors detected when arriving at�the site.. El'.Yes. 1z No 5... Building Sewer(locate on'.site,plan) Depth belowgrade: fleet Material of construction: ❑cast iron ®40 PVC. ` ❑other(explain); Distance from private water supply well or suction line: tee n.water. Comments(on condition of:jomts; venting, evidence of eakage, etc) joints tight proper venting, no evidence of leakage. t5irisp:doc-rev:7126/2018: rdie 5 Official inspection Formi Subsurface Sewage.Disposal System Page 9;&18 Commonwealth of Massachusetts Title 5 O 'rci"2�1 Io spection ,,F.- Subsurface Sewage Disposat-System Form:_Not for.Voluntor Assessments 9-Indian Hilt Road 8 Property Address , Robert Murray Owner Owner's Name- information is Cumma uid MA 02637 03/02/20 required for every q page. City/Town state Zip Code Date of inspection" D. Systemanformation (cont.) 6. Septic Tank(locate on site-plan): Depth,below 12" grade. feet Material of construction . ®concrete ❑metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age.. years, Is age confirmed by a Certifcate;of Compliance?(attach a copy"of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon.tank Sludge depth: 0=1" Distance from top of;sludge to bottom'ofoutlet tee or baffle 33" 0 Scum thickness Distance from top of scum to top of outlet tee or baffle` 8 Distance from bottom of scum.to bottom'of outlet tee.oi•.baffle 14" How were dimensions determined? sludge judge Comments(on pumping=recommendations, inletand.outlet tee or baffle condition;structural integrity, liquid levels as related to'outlet invert, evidence of leakage, etc)* ki�VM._','0 Tee's in;place'in working condition, no signs of leakage:.or over loadingAiquid level is.equal with. outlet invert.Tank does not need pumping at1his time t5insp,doc-rev.712&M18 Title 5 Official Inspection Form:Subsurface Sewage:Disposal System•page .10 of 18 Commonwealth of Massachusetts Title 5 Official Iftoection.-Fdrmr Subsurface Sewage Disposal System Form Not-for Voluntary.Assessments,; 9 Indian Hill Road Property Address Robert Murray Owner Owner's Name information is required for every Cumma 4uid MA 02637 03/02/20 page. City/Town State: Zip Code Date.of-Inspection D. System information (cont:) 7. Grease Trap'(locate on site plan). Depth below grade N/A feet Material of construction. ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene other(explain): N/A Dimensions NA Scum thickness Distance frorif top.of scum to top of,outlet tee or baffle N/A Distance from bottom of scum to,bottom of outlet tee'or baffle., NIA Date of last pumping:_ NIA Date Comments(on pumping recommendations, inlet and outlet tee-or:baffle condition, structural integrity, liquid levels as related to-outlet invert..evidence.of leakage; etc;) N/A 8. .Jight or Holding Tank(tank must be pumped at time of inspection):(locate on site`plan):< Depth.below' grade; N/A Material of construction. [I concrete ❑ metal ❑fiberglass` ❑ polyethylene ❑other(explain):. N/A Dimensions NIA Capacity NIA gallons . Design Flow: N/A gallons per day t5insp:doc•rev.Il16/201$. Title 5 Offaa]Inspection Form:$ubsurtace'Sewage Disposal System Page 1 I.of 18• Commonwealth of Massachusetts Title 5 Official In pecti : h Form Subsurface Sewage Disposal:System Form Not forVolunta Assessment s=. 9 Indian Hill Road - Property Address Robert Murray Owner Owner's Name information is Comma uid required for every G MA: 02637 03/02/20 page. City/Town state Zip Code: Date`of Inspection D. System-Information (Cont.) ., 8 Tight orHold ., Tank(cont.) Alarm present: ❑ Yes ❑`: No Alarm level. NlA. Alarm in workin order.. 9 ❑ .Yes ❑ No Date of last pumping NIA .Date Comments(condition of alarm and'float:switches, etc.): • N/A *Attach copy of current pumping Contract(required) Is°.copy-attached� ❑ .Yes ❑ No 9., Distribution Box(if present mustbe opened)(locate on site'plan) =t 0„ Depth of liquid level above outlet invert Comments(note if box is°level'and'distribution'to outletsequal,any evidence-of solids carryover-any evidence of leakage into orout of box;:etc) H2O box is' evel an'd.solidwith�no sign-of carryoveror leaking`in orout of'box. 1 inlet and 2 outlets t5insp:doc ?ev::7262018 Title 5 official Inspection Forth:Subs ibw Sawage Disposal System•Page 12 or.t8 Commonwealth of Massachusetts Title 5 Official In peat on Forav� Subsurface Sewage Disposal System Form for.Voluntary Assessments`.` 9 Indian Hill Road Property Address. ... Robert Murray , Owner Owners Name information is umma uid MA, ` required for every C 9 02637 03/02/201- _ C'_!Town State i Page �Y .• : Z p Code, Date of.Inspection D. System Information (coat.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑+:'Yes ❑ No" Alarms in working order'. ❑ Yes ❑ No' Comments(note condition Hof pump chamber, condition of pumps.and'appurtenances etc:): N/A- If pumps or alarms are not iri working order,system iS a condltionaCpass 11. Soil.Absorption Syi tem:'(SAS) (locate on site plan, excavation not-required) If SAS not located,explain why N/A,,' Type, leaching pi#s number M00 gallon' ® leaching chambers' number: w/stone ❑ leaching galleries number. ❑; leaching trenches. number, length: El leachrng fields number; dimensions ❑ overflow cesspool number innovative/alternative system Type/name of technology: t5insp.doc•rev.726/2018. Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13.of 18 Commonwealth of Massachusetts 'c al-Ihsopdtioni� Subsurface Sewage ftoosal.System Form-.Not for Voluntary.Assessments ' 9 Indian Hill Road Property`Address Robert Murray Owner Owner's Name information is Cummaguid required for every MA 02637 103/02/20 page. Cityrrown State Zip Code Date.of.insp ection D. System Information (writ.) 11. Soil Absorption System(SAS) (cont.) Comments,(note condition of soil,signs of hydraulic failure, level of.ponding;'dam'p soft, condition of vegetation, etc.): I. soil and stone found clean-5and dry with no pontl n or signs of hydraulic failure 12. Cesspools (cesspool mustbe pumped as part of inspection)(locate on site plan) Number and configuration N/A Depth—top of:liquid to inlet invert Depth of solids layer NIA Depth of scum.layer N/A. Dimensions of cesspool N/A Materials of construction N/A:: Indication of groundwater inflow : - Yes .No Comments(note condition of soil;`sinfygo , condition of vegetation, etc.):. N/A . . ISinsp.doc-rev.7h6=18 Idle 5 Official Inspection Form:Subsurface Sewage.Disposal System•Page 14 of 18 Commonwealth of'Massachusetts . Ti c e 5 O�� Jalt Ins��c�ion ,(�o r ; Subsurface Sewage Disposal System Form=Not for•Voluntary Assessments 9.Indian Hill Road Pr operty ertY Addr ess 'q Robert Murray Owner owner's Name information is Cumma uid required for every q MA 02637 03/0220 ' page. City/Town _ State Zip Code - Date of inspection D. System Information (coif ) s. 13. Privy'(locate`oft site plan).. Materials of construction:, N/A Dimensions N/A . Depth:of solids NIA Comments(note condition.of:soil,°signs of hydraulic failure;Ievel of poriding, condition of vegetation, etc.): N/A A. t5insp.doc 1 rev.7/26MI8 TiUe.S Official fns pection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts ,l Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 9-Indian Hill Road' Property Address Robert Murray Owner Owner's,Name information is uid Cumma required for every 4 MA 0207 03/02/20 page. City/Town State; Zip Code` . Date of Inspection 'D. System information on . 9 14. Sketch Of Sewage Disposal System: Provide a view Of the Sewage di$posal.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 . JZ 'hand-sketch in the area below. drawing attached separately. 8 a aAz I 3 '3 �6 2S i'S t5insp.cim•rev.7@6/201ti. Title 5 Of6dal Inspection Form Suhsurface'Sevrage Disposal System r P 'I of 18 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form:.-,,Not for Voluntary Assessments: 9 Indian Hill Road. Property Address Robert Murray. Owner Owner's Name information is Cumma uid required for every q MA, 02637 03/02/20 page. . City/Town State Zip cooe Date of Inspection . D.'System Information (cont ) 15. Site Exam: ® Check Slope ® Surface water `. ®..Check cellar ® Shallow.wells Estimated depth to high ground water: ` 12 5'+ feet Please indicate all methods used to determine the high ground.waterelevation , ® Obtained from.`systern.design plans�on:record If.checked, date of design plan reviewed: 8/16l16 Date. ❑ Observed site.'(abutting property/observation hole within 150.feet of SAS) ❑ Checked with local Board of Health.=explain ❑. Checked with aocal excavators installers-(attach documentation) ❑ Accessed USGS database-explain; You must describe`how,you: stablished the high ground water elevation V�- w f test hole data shows bottom of SAS EL' 16.36,an bottom of test.hole..with no water encountered EL=8.5.Giving 7..65 of seperation Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5insp.doc rev.7r2M018, Title 5 Official Inspection Fora:subsurface Sewage Disposal Syslem•Page 17 of 18 Commonwealth of Massachusetts Yule 5 Official Inspection Form. Subsurface Sewage Disposal:System Form-Not:for Voluntary Assessments . 9 Indian Hill Road Property Address t ' Robert Murray Owner Owners Name information is Cumma uid MA 02637 03/02/20 required for every 4 page.. City/Town State Zip Code Dateof Inspection . E. Report Completeness Checklist Complete.all applicable sections of this form inclusive of: ® A. Inspector Information Complete alf fields in this section: ® B:Certfication: Signed,& Dated and 1, 2, 3,or 4 checked ® C. Inspection-Summary 1,2 3 or.5 completed as appropriate 4(Failure Criteria)and 6 (Checklist};completed ® D, System Information:' For 8:TighVHoiding Tank—Pumping contract attached For 14:Sketch`of Sewage Disposal Systern drawn on pg..16 or attached For 15:Explanation of estimated depth to.high groundwater included. t5in5p:doc•rev:7/26/2018. Tile 5 Official Inspection Form:Subsurface Sewage.Disposal System-Page 18 of 18 TOWN OF BARNSTABLE LOCATION 57 /,,0140v�,*- /�/��' JP4 SEWAGE# ®1e—°'Z 31 VILLAGE ASSESSOR'S MAP.&PARCEL3.3 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY i,1'Ti�' !o Pe . oi.. LEACHING FACILITY:(type) c�dz� ,2'/►,g ra .P (size) !ems o 04-W O/6r NO.OF BEDROOMS OWNER PERMIT DATE: COMPLIANCE DATE: v17 Separation Distance Between the: i7-ev� Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility S"a -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 �/1 W jgr' L'�/ j�eo,,vT �-- LE No. al Fee c✓ THE COMMONWEALTH OF MASSACHUSETTS Enteredincomputer: PUBLIC HEALTH DIVISION'- TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2ppliLation for Disposal *pstrm Construction Permit Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System �ndividual Components Location Address or Lot No. Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 3J64:!!!r" od-d- �'' Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. 4p,7 O, Type of Building: Dwelling No.of Bedrooms `'r Lot Size sq.ft. Garbage Grinder( ) Other Type of Building —�, No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) © gpd Design flow provided / gpd Plan Date T���� Number of sheets Revision Date Title Size of Septic Tank���'�Jr'6�' /o®O 2!5Type of S.A.S. Description of Soil L r.::5,Le _ G'a Nature of Repairs or Alterations(Answer when applicable) ��• r/ �i�� Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Heajulp Signed Date Application Approved by Date p Application Disapproved by Date for the following reasons Permit No.: � �� � Date Issued i w, 1Vo. /J Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer—Yes PUBLIC HEALTH DIVISION'-=-Tdm OF BARNSTABLE, MASSACHUSETTS 'k 2pplitatlon for ]Disposal *pstem ConBtrUttion Permit Application for a Permit to Construct( ) Repair(A)"Upgrade( ) Abandon( ) ❑Complete System �ndiidual Components Location Address or Lot No.�P 214'0/. 1-1 641ZZ 0 jj Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 3.� = o ems- ��' 'h�v/ZOr JV Installer's Name,Address;and Tel.No. Designer's Name,Address,and Tel.No. d .J"o a' O?.!' Type of Building: t f Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building 4:: tZ a No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) CT gpd Design flow providedS� gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank t�J+'/�'T/ram /oe�O ;!!!`'I'ype of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) �Pc�eQ �'�i�/�d• Date last inspected: Agreement: a , The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions bf Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Healthp e. Signed Date e102,71 + Application Approved by Date ��!} Application Disapproved by Date r for the following reasons J Permit No.���� ?j Date Issued \\ ----------------------------------------------,-- -----------__-_______-__-_______-__---------------_.__ j________________-_______-______ jay THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliante THIS IS TO CERTIFY,that th On-site Sewage Disposal system Constructed( ) Repaired(� Upgraded( ) Abandoned( )by V/ at 9 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.c—/t-J J.'j 1 dated Installer"5� .�GEC 'd��� Designer •d/!A//O A6, !!!W ,/'O A' Bt'✓', #bedrooms Approved design flow a :-g gpd The issuance of this permit hall not b construed as a guarantee that the system will ctiorr es'. ed� Date �•;7jZ Inspector ----------------------------------------------------- - No. Fee // THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS MIsposal *pstem Construction Permit Permission is hereby granted to Construct( ) .,Repair( . ) Upgrade( ) Abandon( ) System located at /y/Lz lo 4e7 �j��/✓e and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or spec l=conditions; Provided:Construction must be dimple ed w'thin three years of the date of this permit. Date /�/ So Approved by .•-� __ _, Town of Barnstable �VEro Regulatory Services Richard V.Scali,Interim Director 9��A,O Public Health Division "hDs Thomas McKean,Director 200 Main Street:;Hyannis,MA 02601 f Office: 50&862-4644 Fax: 508-790-6304 Installer&Designer Certification Form Date: �b Sewage Permit# �Z T/Assessor's MapTarcel Designe . �� Installer: Myl� Address: Address: �7 - On f yJ� was issued a permitto install a (date) (installer) septic system at Hu.) !'vim based on a design drawn by (address) dated (designer) I certify that.the septic system referenced above was installed substantially according to the design,which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State &Local Regulations. Plan revision or certified as-built by designer to follow. Strip out(if required)was inspected and the soils were found satisfactory. I certify that the system referenced above was constructed in MAI njiance with the terms of the ]1A approval letters (if applicable) i- �.. N DAVID y c (Installer's Signature) NI B. No'1066 aisle go ' 's'tNITAS',�I'�, (Des s Signature) (Affix Desi y;__ Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:1SepticMesiper Certification Form Rev 5-14-13.doe TOWN OF BARNSTABLE LOCATION /ZIZe'`` 0-0 SEWAGE# 0,"4< VILLAGE ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO.'-I'"' SEPTIC TANK CAPACITY. w,I'Ti LEACHING FACILITY:(type) ,z'i;+,g ` ,P (size) NO.OF BEDROOMS OWNER PERMIT DATE: COMPLIANCE DATE:' a-7 .)7 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility ra 4,e t_ 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 �xiSji rr , .2 / ems- "� _ i Town of Barnstable P0. Department of Regulatory Services MASS. Public Health Aivision Date ' MASS. ie3➢ 200 Main Street,Hyannis MA 02601 Date Scheduled r tt .a•slime . � Fee Pd. .I v//inm �,I Sall ...� Suiitiability,A►ssessment f'or Sewage spo,sa l Performed By:- C S Witnessed By: LOCATION& GENERAL INFORMATION Location Address �j���,d�/ /`� E4t> Owner's Name G �.►y " �-1�e✓� Address Assessor's Map/Parcel: `� �� J'- Engineer's Namc �� '✓��' �'tr�' t NEW CONSTRUCTION REPAIR Telephone 4 Land Use ". �' =+A �E�Oc'�l� • Slopes(%) Surface Stones . Distances from: Open Water Body ft Possible Wet Area ft Drinking Wafer Well {t Drainage Way ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands In proximity to hoes) Alt ----------------- f Parent material(geologic) Depth to Bedrock i Depth to Groundwater. Standing Water in Hole: Weeping fl'am Pit Face Estimated Seasonal High Groundwater . DETERMINATION FOR SEASONAL JUGH WATER TABLE <.:.. Method Used: Depth Observed standing in obs.hole: lu. Depol to sell mottles: - s Depth to weeping from side of obs:hole: Itt' Index Well# in, Ornundwntttr AdJustment ft• Reading Date: Index Well level _ p ,factor _ ..._. _._ � Aq.Gt•aunsiwtiter Level ,;,,_, PERCOLATION TEST bate Thub Observation Hole tp Time at 9" �. Depth of Pere �t� ' •,• ' Time at 6" Start Pre-soak Time @ Time(9"-6')' End Pre-soak 2• � ` / t r . Rate Min./Inch /�- *4 sr = t:.! Site Suitability Assessment: Site Passed Site Failed: Additiotial Testing Needed(Y/N) Original! Public Health Division Observation Hole Data To Be Completed on Back-------- �l ***If percolation test is to be conducted within too' of wetland you must first notify the � Barnstable Conservation Division at least one(1) week prior to beginning. Q:\S EPTIC\PERCFORM.DOC DEEP-OBSERVATION ROLE LOG Hole# Depth from Soil Horizon Soil Texture Sdil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Stnucture,Stones;Boulders. onsistency.%'arayel) ws x:: C an y.....? 1 DEEP OBSERVATION HOLE LOG Dole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Orayel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%O DEEP OBSERVATION MOLE LOG' Hole# Depth from Soil Horizon Soil Texture Sall Color gall Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consistency. s Flood Insurance Rate Map: Above 500 year flood boundary No_ Yes ._✓____ Within 500 year boundary No Yes _ Within 100 year flood boundary No.]Z Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring par o s aerial exist in all•areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of h turally occurring per ious material? Certification �h I certify that on. 1!� (date)I have passed the soil evaluator examination approved by the Department of Environ ental Protection and that the above analysis was performed by me consistent with the re uired training xp tis and experience described in 10 CMR I.S.P. Signature DatLo Q:\SEPTIC\PERCFORM.DOC t S 9 Commonweallh of Massochusefls Rf + Executive Office of Environmental Affairs ' ✓U CF��Ef' g.; Environmental ProftcOion y��Tti FpTrAB�F N William F.Weld Governor 4• Trudy Coxo y Sec1l14'COLA David B. St►uhs 4 commissioner a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART'A CERTIFICATION Property Address: Address of Owner: Date of Inspection: 'DE--97, f `• '(If different) Name of Inspector: izo<_v Company Name, Address and Telephone Number. Ail i> (-II(IIIIC:AIION SIAIIAIINl rtvlll� II1.11 I hdrl Iu•I�un.11ly nitipl r ll 11 Ilir •,r•w.y!.r• Ili,l tr..il`sys.11•nl ,11 Ilu. .ulrin•,, .u1rI.tI1.11.tlrt• i111urni.N.n,r1r nyxrittvl In•luv i5 lnu, :Iccur,llt and complete as of the time of inspection. she inspection was peiforined based on, my trailing and experience in the proper function and maintenance of on-site sewage disposal systems. The system: t/ Passes .` _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority a Fails fnspeelor's Signs ce: ; �� 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 repot, to the appropriate regional office of the Departrnehl of Environmental Protection. The original should be sew to tux• system owner and copies sem to the buyer, 4 applicable and the approving aw.hority. INSPECTION SUMMARY: Check A, B, C, or D: A) S71have PASSES: not found an information'which indicates that the system violates an of the failure criteria as defined in 310 CMR 15.303. Y Y Y Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement•or repair, ' passes inspection. _ Indicale 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 exhltration, 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 8/15/95) 1 One Winter Street a Boston,Massachusetts 0210E a FAX(617)556-1049 o Telephone (617)292-5500 t 40 Primed on Recycled Psper { SUBSURFACESEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) property_Address; C e' `j N,Q, Owner. `-- Date of Inspection BI 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 oruineven distribution box. The system will pass inspection if(with approval of the Board of Health): • -- - broken pipes) are replaced ' obstruction is removed distribution box is levelled or,replaced . _ The sy 1.stem 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: /-,4 Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the o 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: he c\'StE'm hd� a senuc tank anu.son ausurpuun system diw is wlllun 103 icci iu o ) or tr,su i&mac,Diu ci supp. u,a.) tv a — surface wager supply. �' `• ,The system ha a septic rani and soil absorption system and is'within a Zone I of apublic water supply well. The_Syste_m.has..a.,septicaank.and soil absorption system and is within 50 feet of a p ivate water supply well. - _ The system hes a septic tank and soil absorption system and is less than 100 feet,but SO 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 , D] SYSTEM`FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of e into facility or system component due to an overloaded or clogged SAS or cesspool. Bac p sewage Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or. cesspool. �A 2 (revised 8/15/95) --` —� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM — PART A CERTIFICATION (continued) Property Address: � -► rJ� �'�11v.t Owner: ►1,.�r�r. z: Date of Inspection ` �,.��7 D) SYSTEM FAILS-(continued): / Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 112 day flow. Required pumping more than 4 times in the Iasr'year NOT due to clogged or obstructed pipe(s). Number of times pumped r/ 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:wiihin a Zone I of a public well., Any portion of a cesspool or privy is within 50 feet of a private water supply well. i / 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: �. -The following criteria apply to large systems in addition to the criteria above: The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a.surface drinking water supply the•system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a public water suppiy well The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. fit• '� .. ,' - 4 ♦ r .. ��. t .. , � r .. •. � .i. ..� - �mom. .``, g r - (revised. 8/15/95)� 3 rt Ikv SUBSURFACE SEWAGE DISPOSAL SYSTEM-INSPECTION FORM _-• __... . PART B CHECKLIST Property Address: �l -i��<u,ts,vT'r-0i— Oil,, Owner-_�E cw_) Date of Inspection: Check if the following have been done: Lpumping 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. 2The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow C/The site was inspected for signs of breakout. t 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. ,Xhe 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 faciG;y o•.,,c ;� : ' occupants, if d:5er— from ovmer; were provided with information on the proper maintenance of Sub- Surface Disposal System. h 'y t. (revised 6/15/95) 4 �•. Y � y SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM INFORMATION Property Address: Owner;�ti<<n.,ut-- Date of Inspection: FLOW CONDITIONS RESIDENTIAL Desig tzallons Number of bedrooms Number of current residents:v4 Garbage grinder (yes.or no):z Laundry connected to system (yes or no):y Seasonal use (yes or no): r� Water meter readings, if available: N� Last,,oate of occupancy;.'.... COMMERCIAUI NDUSTRIAL- Type of establishment: Design flow: gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)__-_ Non-sanitary waste discharged to the Title 5 system: (yes or no) Water meter readings, if available: Last dale of occupancy: OTHER: (Describe) Last date of occupancy' GENERAL INFORMATION PUMPING RECORDS and source of information: - ) J7Jw1�,��5� T(Aic> `! �„rS . Pwl(_/� J� 9q System pumped as part of inspection: (yes or no)_ " If yes, volume pomppd. gallons , Reason for pumping: TYPE O,,VSYSTEM - Septic tank/distribution box/soil absorption system j Single cesspool Overflow cesspool . Privy Shared system(yes or no) (if yes, attach previous inspection records, if any) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no)L (revised 8/25/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: I NCQ�'N r._)"I-Ir"t Owner: rtr��tic�•r ` Date of Inspection: SEPTIC TANK: ' (locate on site plan) rt Depth below grade: O VC- Material of construction: oncrete _metal _FRP other(explain) Dimensions: 5t Sludge depth: 4 Distance from top of sludge to bottom of,outlet tee or-baffle: 7 X Scum thickness: cl rf Distance from top of scum to top of outlet tee or baffle: Q 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 i vert, structural integrity, evidence of leakage, etc.) � �C� S � �A-S G�Pe " 9GdYJ5 IF GREASE TRAP: I (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: -Scum-thickness: _.___..__a........__..._.. r, Distance from top of scum to top of outlet tee or baffle: Dictance from bottom n, critm In hntlnm of ou"pt 1pe O' ha?Ile' Comments: T (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural I' integrity, evidence of leakage, etc.i 1 (revised e/15/95) 6 SUBSURFACE SEWAGE DISPOSAL',SYSTEM INSPECTION FORM PART C 4 SYSTEM INFORMATION(continued) Peopert�Address: '-1-p :.�'i 1 <<f i C v;nn►M� -_ Owner: Date of Inspection: 7 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: Material of construction: _concrete_metal FRP —other(explain) Dimensions: : Capacity: gallons Design flow: gallons/day l Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:— (locate on site plan: r' Depth of liquid level above outlet invert: Comments: mote n ievei ano distributlw: eyua�, e%.6cnce of sulid: ca:r)u�er, evidence of leakage into or out of box, etc.) PUMP CHAMBER: A/ (locate on site plan) Pumps in working orden(yes or no) , Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) ' 7 A - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: �1'.Zlv�. r�Z��f: (t' k Date of Inspection,, SOIL ABSORPTION SYSTEM (SAS): i•r ',` (locate on site plan, if possible; excavation not required, but may be-approximated by non-intrusive methods) .If-not determined to be-present,.-explain:_._., . Type. leaching pits, number: leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) CESSPOOLS; (locate on site plan) -.__Number and configuration: + LL Depth-top of liquid to inlet invert: Depth of solids layer. Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of gruund�%ate:. 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: 1 (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 8/i5/95) nc 8 . - t f .* f • • J t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C _ SYSTEM INFORMATION (continued) Properly Address: �T iv t mot.,✓ /���� /Q ,, M vti); Owner• Z,i wN er Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' 0 r. 4 DEPTH TO GROUNDWATER +• _ - Depth to groundwater ✓ L feet (. method of determination or approximation: FA o (, -4.- H. la:V"'e (revised 8/15/95).' •' 9 ASSESSORS MAP : 3�� _ TEST HOLE LOGS v - PARrf I. : 1) The installation shall c,�rnply ►villr `fille V rui,l 'fu%vrj ui z��j Ilurird of , SOIL EVALUATOR :ZONE: /-/0-- r � I lc alli Re ulal'ons.WITNESS : 2) " 1°he installer shall verify the location of utilities, sewer inverts and septic REFERENCE � c � DATE: _1 ) components prior to installation and setting base elevations. PERCOLATION RATE': -C-Z WA ! 3 All pravity septic piping to be 4 inch Sell 40 PVC at 1/8" per Foot. The first ?" 1`,�7. � v, �� ✓ �/� . ��, two lief out of the d-box to the icaching shall be level. 4) 'I°his plan is not to be utilized for property line determinalion nor an , other TH- I TH-2 p p Y ) -'8 purpose other than the proposed system installation. -..- �� �� !/ / l j - �' l t 5) All septic components must meet 'Title V specifications. t fi) Parking shall not be consintcted over If 10 septic components. ��� � l �1b 7) "I'he property is bounded by property corners and property lines. llnl 'r1 -� —L-- 8) The property owner shall review design considerations to approve of total y la boftk` LJIIIT' desi ► pP LOCATION MAP �_ -. � � _ — — C D�� �n flow and member of bedrooms to be considered tier design. Receipt �,� of payment for the plan and installation based on the plan shall he deemed approval of the design flow by the owner. 2O , 6� 9) The existing leaching or cesspools shall be pumped and filled with material per Title V abandonment procedures. Those within the proposed SAS shall �' he removed along with contaminated soil and replaced with clew p n sand per 3 itle V specs. j — - `✓ v l O)System components to be (O feet from waterline. Sewer !ines crossing the T�,�,, i z/ — — ��� 1�0�� water lire shall be sleeved with 4 inch SC[I 4O I'VC with ends grouted if applicable. "fhe proposed SAS is being installed below the water service SEPT l C SYSTEM DESIGN line. "I°he line is to be sleeved as aforementioned and maintained in place. of - c 11) Ira garbage grinder exists it is to be removed and is file responsibility of , ON owner to ensure such. p Y h / FLOW ESTIMATE 12)The installer is to take caution in excavation around the gas line if such exists. yr, BEDROOMS AT -' GAL/DAY/BEDROOM - GAL/DAY 13)"Toe installer shalt verily the location, quantity and elevation of the sewer - % lines exitint, file dwelling brior to the installation. SEPTIC TANK I4)"This plan is representative only that a system can fit on a property meeting `I'itle V requirements. Z1,7- v4 �� GAL/DAY x 2 DAYS - GAL USE J GALLON SEPT I C TANK L�C1t<1t4r) Lo7- Al le � h SOIL ABSI r ON SYSTEM vtl SIDE AREA: 7i� , Z�j �-l2 � X ZX �� � � � i�� o� (;AVID �y BOTTOM AREA: ' Z37i2� ►' ft4ASON c r �ou o. toss y' SEPTIC SYSTEM SECTION r, + F 1+ GAL .�^ SEPTIC TANK7D 8 24 SITE AND SEWAGE PLAN LOCATION : G� L�Di 1 4u, ZO r" rO ° ►L PREPARED FOR : wit\ r SCALE: a W 1 , DAV I D B . MASON � DATE : I(o O V�i f/ DBC ENV I RONMEN`TAL DESIGNS EAST SANDWICH . MA w DATE HEALTH AGENT ( 508 ) 833- 2177 Z Low 01-1