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HomeMy WebLinkAbout0212 INDIAN TRAIL - Health 212 INDIAN TRAIL, BARNSTABLE A= 5 F a - i 9 66 W. Barnstable 48 Scorton Hill Rd. , II A= 111-020 i qq, 1 I ypi 4 I j TOWN OF BARNSTABLE LOCATION Tr 1 SEWAGE # VILLAGE ASSESSOR'S MAP & LOT — INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by - -- -� � Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: o� t � mrail 6ammagvdr n Owner; Date of Inspection:`L_ —O 3 SKETCH OF SEWAGE DISPOSAL SYSTEM r k r Provide a sketch of the sewage disposal system includin benchmarks.Local g lies to at lease two permanent reference landmarks or e all wells within 100 feet.Locate where public water supply enters the building. I a �! Commonwealth of Massachusetts Y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 212 Indian Trail Property Address James Dunn Owner Owner's Name information is Cumma uid MA 02637 05/27/09 required for Q every page. Cityrrown State Zip Code Date of Inspection inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the computer,use 1. Inspector. only the tab key to move your Michael Kellett - cursor-do not Name of Inspector use the return key. Aardvark Environmental Inspection Company Name ffi P.O. Box 896 Company Address East Dennis MA 02641 Cityrrown State Zip Code 508-385-7608 S13742 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails Needs Further Evaluation by the Local Approving Authority rG 05/30/09 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the.system will perform in the future under the same or different conditions of use. 9 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 212 Indian Trail Property Address James Dunn Owner Owner's Name information is 4 required for Cumma uid MA 02637 05/27/09 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board.of Health,will pass. Answer yes, no or not determined (Y, N, ND) in the ❑for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old'or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 212 Indian Trail Property Address James Dunn Owner owner's Name information is q required for Cumma uid MA 02637 05/27/09 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or.privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 212 Indian Trail Property Address James Dunn Owner Owner's Name information is q required for Cumma uid MA 02637 05/27/09 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® 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 %day flow El ® 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. An portion of cesspool or privy is within 100 feet of a surface water supply or Y P P P Y PP Y ❑ ® tributary to a surface water supply. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments s.' 212 Indian Trail Property Address James Dunn Owner Owner's Name information is q required for Cumma uid MA 02637 05/27/09 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water 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 If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 212 Indian Trail Property Address James Dunn Owner Owner's Name information is required for Cummaquid MA 02637 05/27/09 every page. Cityrrown state Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? 0 ❑ ® 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)] Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 212 Indian Trail Property Address James Dunn Owner Owners Name information is q required for Cumma uid MA 02637 05/27/09 every page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate-sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: 11/08 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): Commonwealth of Massachusetts Title 5 Official Inspection Form , Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �.' 212 Indian Trail Property Address James Dunn Owner owner's Name information is q required for Cumma uid MA 02637 05/27/09 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) r General Information Pumping Records: 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: Type of System: t ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool El 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) ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 212 Indian Trail w Property Address James Dunn Owner Owner's Name information is required for Cummaguid MA 62637 05/27/09 every page. City/Town State Zip Code Date of Inspection D. System Information(cont.) Building Sewer(locate on site plan): Depth below grade: 1.4 G . .. feet y Material of construction: ❑cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet <. 1 Comments(on condition of joints, venting, evidence of leakage, etcJ: Septic Tank(locate on site plan) Depth below grade: 1.0 feet Material of construction: ❑ concrete, D metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years 3 Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal 3,' . Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 29„ " 2" Scum thickness g Distance from top of scum to top of outlet tee or baffle 61 15„ Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? measured Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r.' 212 Indian Trail Property Address James Dunn Owner Owner's Name information is q required for Cumma uid MA 02637 05/27/09 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was sound and tight with tees in place and liquid at outlet invert. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): I Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r ' 212 Indian Trail Property Address James Dunn Owner Owner's Name information is q required for Cumma uid MA 02637 05/27/09 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: _ gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert even 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.): The box was level and tight with no sign of carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 212 Indian Trail Property Address James Dunn Owner Owner's Name information is required for Cummaquid MA 02637 05/27/09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 16'x24' ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The system has a 16'x20'stone field which showed no sign of pondig or failure in the stones I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 212 Indian Trail Property Address James Dunn Owner Owner's Name information is q required for Cumma uid MA 02637 05/27/09 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Commonwealth of Massachusetts Title 5 Official -Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 212 Indian Trail Property Address James Dunn Owner Owner's Name information is Cummaguid MA 02637 05/27/09 required for State Zip Code Date of Inspection every Page, City/Town D. System Information (cunt.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet Locate where public water supply enters the building. \El 3� t� a� I ` Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 212 Indian Trail Property Address James Dunn Owner Owner's Name information is Q required for Cumma uid MA 02637 05/27/09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 20.0 Estimated depth to high ground water: feet 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 ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ® .Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS maps show an elevation of over 20.0 feet. c ' COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OFENVIRONMENTALAFFAIRS _ t DEPARTMENT OF ENVIRONMENTAL EROTF¢��Ey,���p2I �py .r`� APR 2 7 2003 TOWN OF BARNSTABLE _ HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM FORM PART A CERTIFICATION S�-I l l �o . .; 33� Property Address: Dr Alexander MA 21 2 Indian Trail, Cummaquid, PARCEL. Owner's Name: Owner's Address: LOT �Z�Date of Inspection: 4.- •-- Name of inspector:(please print) W i l 1 i am E -Roo i n son Sr. Company Name:. William E. Robinson Septic Service Mailing Address: P 0'-Box" 1089 Centerville MA Telephone Number: (508). _ 775-8776 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and.that the information reported, below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am.a:DEP approved system inspector,pursuant to Sec ion 15340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: _L Dates ��/1777 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board-of Heatthlor DEP)within 30 days of completing this inspection.If the system is a shared system or has a design now of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approxing authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM NOT FOR VOI:UN'TARY`ASSESSMENTS RM SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO PART A CERTIFICATION (continued) Property Address: - Owner. .) Date of Inspection: r. Inspection Summary•;Check A,B,C,D or E/ALWAYS complete,alt of Section D A. System Passes: ✓/ ion which indicates that any of the failure criteria described in 310 CMK I have not found any informat 15.303 or in 310 CMR 1'5.304 exist.Any failure criteria not evaluated are indicated below. Comments:---- B. stem Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaire .The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass: Answer es,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. e septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsoun exhibits substantial infiltration or exfiltration or tank failure is unmment:System will pass inspection if the existing is replaced with a complying septic tank as approved by the Board`bmcalth: •A me 1 septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance less than 20 ears old is available. indicati g that the tank is y ND a lain:. Observation of sewage backup or break out or high stati c water level in the distribution box due to-broken or PP o tructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with app vat of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND cxp in: e system required pumping more than 4 times a year due to broken or obstructed pipe(s).The hem will pass ins ection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is rttnoved ND a lain: Page 3 of 11 OFFICIAL INSPECTION FORM::.NOT FOR VOLUNTARY ASSESSMENTS 'SUBSURFACE SEWAGE DISPOSAI'SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 212 Indian Trail - Owner: Date of Inspection: ` - -s63 C. Further Evaluation is Required by the Board of Health. Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failinn to protect publichealth safe or the environment. 1. System will pass unless Board of Health determines in accordance with'310 CMR 15.303(1)(b)..that the System.is not functioning in.a manner which will protect public health,safety.and.the environment: _ Cesspool or privy is within 50 feet of a surface water lCesspool or is within 50 feet of a bordering vegetated`wetland or a salt marsh,,: privy,. 2. S/stem will fail unless the Board of Health(and Public Water Supplier,if any)determines.that.the syst 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 su face water supply or tributary to"a surface water supply: \ The system has a septic tank and SAS and the SAS is within a Zone l 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 front a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform .bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and.. the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. O,ther: 3 Page 4 of I 1 , OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:Z, T ... ...-. .f Owner. g Date of inspection: D. System Failure Criteria applicable to all systems:. Youlmust indicate"yes"or"no"to each of the following for all inspections: Yes No i Backup of sewage into facility or system component of the due to ound or load a water due to an overloaded or Discharge'or ponding of effluent tot the surface , !� , T Sta tic ced SAS or CCSSP901: lquid 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 lessthan'/:day flow equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number — f times pumped - y portion of the,SAS,cesspool or privy is below high ground water elevation. t of a surface water supply or tributary to a surface y portion of cesspool or privy is within 100 fee ater supply. 1, y portion of a cesspool or privy is within a Zone I of a public well. I �1ny portion of a cesspool orprivy is within 50 feet of a pnyate water supply well. �ny portion of a cesspool or privy is less than 100 feet.but greater than 50 feet from a private water )supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile Organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia / nitrogen and nitrate nitrogen.is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this formA (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. La a Systems: O b00 d to 15,000 To be cd sidered a large system the system must serve a facility with a design now of l gP gpd- You Ast indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes n0 the system is within 400 feet of a surface drinking water supply i 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 If you,have answered"yes"to any question in Section E the system is cons f d a aM 1ge system con id Or tiered "yes"in Section D above the large system has failed.The vvvit�or or significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304!The system owner should contact the appropriate regional office of the Department. 4 Page S of i I ' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST' Property Address: 212 Indian Trail Cummaguid, MA _ Ownernr nr_ cAI Pxander Date of Inspection: Check if the following have been done.You must indicate`Yes"or"no"as to each of the following: Yes No Pumping information was provided by the owner,occupant,or.Board of Health, _ _ Were any of the system components pumped out in the previous two weeks? . I/ _ Has the system received normal flows in"the previous two week period? _ Have large volumes of water been introduced to the system recently or as part of this inspection"? _ Were as built plans of the system obtained and examined?(If they were not available note as,N/A) _41 _ Was the facility or dwelling inspected for signs of sewage back up? _ Was'"the site inspected for signs of break out? w _ Were all system components,excluding the SAS;located on site 7 Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems.?_ The size and location of the Soil Absorption System(SAS)on the site has been determined based on:. Yes no f//r 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 CUR 15.302(3)(b)J " Page 6 of I 1 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 21 2 T n rl i a n m,-a i l Owner: Date of Inspection: FLOW CONDITIONS RESIDEN.TIAI. Number of bedrooms(design): Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x N of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no):,&T,(if yes separate inspection required] Laundry system inspected(yes or noAL Seasonal use:(yes or no):/ t� Water meter readings,if available last 2 Years usage d - Sump pump(yes or no): Last date of occupancy: 3 COM RCIAIANDUSTRIAL Type of es blishment: Design no (based on 310 CMR 15.203): gpd' Basis of de ign flow(seats/persons/sgft,etc.): Grease tra present(yes or no):_ Industrial aste holding tank present(yes or no):— Non-rani waste discharged to the Title 5 system(yes orno) _: Water ter readings,if available: 2001 _2n02 = 122,000/ 2002-2003= 109 ,000 Last to of occupancy/user OTN (describe): GENERAL INFORMATION Pumping Records Source of information: C�q GJ J-6 0,� Was system pumped as part of the inspection(yes or no): U If yes,volume pumped:_gallons--Now was quantity pumped determined? Reason for pumping: TYPE F SYSTEM eptic 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) _Tigbt tank Attach a copy of the DEP approval _Other(describe): / Approximate age of all comp ne ats,date installed(if known)and source of information: T Were sewage odors detected when arriving at the site(yes or no):A�� 6 f Page 7 of 11 OFFICIAL INSPECTION FORM NOT-FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued);: Property Address')1 a T than Trai I Own Cummaquid?4A Date o risp '6 '3 BUILDING WER(locate on site plan) Depth below gra e: Materials of cons� coon:_cast iron _40 PVC_other(explain): Distance from pri ate water supply well or suction line: Comments(on co ition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: /(locate on site plan) Depth below grade: Material of construction: 1/concrete—metal_fiberglass—polyethylene other(explain) If tank is metal list age:— Is age confirmed-by a Certificate of Compliance(yes or no):_(attach a copy of certificate) _ Jv ` yn Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: _ Scum thickness: /v ' Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom f outlet tee or bafne:e:�3_�J How were dimensions determined: 0 Y., 6 e. ,-,2 S Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of.leakage,etc. : �. izv GREASE RAP:—(locate on site plan). Depth belo grade:— Material of onstruction:—concrete_metal—fiberglass—polyethylene_other_ (explain): Dimensions: Scum chic ess: Distance fir in top of scum to top of outlet tee or baffle: Distance om bottom of scum to bottom of outlet tee or baffle: Date of I t pumping: Comment (on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels - s as relate to outlet invert,evidence of leakage,etc.): 7 Page8of11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION PART C SYSTEM`INFORMATION(continued) PropertyAddress: 21 2 Tn� Trail ('nmm^rtnirl _N� Owner: Date of Inspection: TIGHT or H LDING TANK: (tank must be pumped at time of inspection)(Iocate onsite plan). . Depth below gra e: _ Material of cons coon: concrete- metal fiberglass_polyethylene other(explain): Dimensions: Capacity. allons Design Flow: allons/day Alarm present(ye or no): Alarm level: Alarm in working order(yes or no): Date of last pum g: Comments(con tion of alarm and float switches,etc.): DISTRIBUTION BOX: ••� if resent must be opened)(locate on site plan) . ( p Depth of liquid level above outlet invert: Comments(note if box is level and distribution t outlets equal,any evidence of solids leakage into or out of box,etc.): carryover,any evidence of � "� PUNIP CHA BER: (locate on site plan) Pumps in work• g order(yes or no): Alarms Lis ng order(yes or no): Comments(no condition of pump chamber,condition of pumps and appurtenances,etc.): 8 , Page 9ofII OFFICIAL INSPECTION.FORM-NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 212 1r}d—Lan. Mr-;I Owner Cum�Q P4A tl d�— anci Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): /(locate on site plan,excavation'not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: lea ing galleries,number: aching trenches,number, length: leaching fields,number,dimensions: a 41` -1-h {� 7 overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, CES POOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Numb r and configuration: Depth—top of liquid to inlet invert: Depth� Yf solids layer: P De th of scum la er• Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comme is(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY (locate on site plan) Materi is of construction: Dime signs: Dept of solids: Co ents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of l l OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address rail Owner. ter Al Pxand^r Date of Inspection:y. '9 p SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. i � 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 212 Indian Trail Cummaquid, MA - Owner: Date of Inspection: 3 SITE EXAM Slope Surface water Check cellar Shallow wells 4 Estimated depth to ground water 9-0 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how,you established! e high ground water ele tion: /ati Gam! b !I 'kJ e 'M 11 COMMONWEALTH OF MASSACHUSETTS r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON. MA 02108 617-292-5500 WILLIAM F WELD TRUDY CORE Governor Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION 212 Indian Trail Property Address: Address of Owner: Dennis Stock Date of Inspection: ��`J`f`�` Rl� 11 (If different) Name of Inspector: Wm E Robinson Sr I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: Wm E Robinson Septic Servi .A Mailing Address: PO BOX 1 089 CPntPryi 1 1 MA 02632 Telephone Numberz, 5 0 8 7 7 r,_R 7 7 6 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: /Pa tsses _ Conditionally Passes - Needs Further Evaluation By the Local Approving Authority Fails Inspector's 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 314D CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: BJ YSTEM 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. Indi ate 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 conforming septic tank as approved by the Board of Health. (revised 04/25/97) page 1 of 10 DEP on the World Wide Web: http:ltwww.magnet.state.ma.usldep �s'j Printed on Recycled Paper r r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 212 Indian Trail Cummaquid. Owner: Stock Date of Inspection: 11-191-47 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). Describe observations: 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 pipes) are replaced obstruction is removed CJ FURT ER EVALUATION IS REQUIRED BY THE 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 the ublic 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 PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE NVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS 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 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 (revised 04/25/97) Page 2 of 10 -�R SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 212 Indian Trail Cummaquid Owner: Stock Date of Inspection: D] SYSTEM FAILS: You mu indicate ei;?:er "Yes" or "No" as to each of the following: have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis fo this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct th 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 112 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. E] LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: he 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 T 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 II of a public water supply well) The wner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requ ements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 212 Indian Trail Cummaquid. Owner: Stock Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _ As built 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. _ AII_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: v _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. _ Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)] (revised 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 212 Indian Trail Cummaquid. Owner: Stock Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: 4P t Q Q.p.d./bedroom for S.A.S. Number of bedrooms: 3 y Number of current residents:- 2--Garbage grinder (yes or no):_&p . Laundry connected to system (yes or no): Seasonal use (yes or no): S Water meter readings, if available (last two (2) year usage (gpd): 96 — 97 27 , 0009 Sump Pump (yes or no):,61-16 97 _ 98 8, OOOg Last date of occupancy: C MERCIAUINDUSTRIAL: Type f establishment: Design flow: gallons/day Grease rap present: (yes or no)_ Industri I Waste Holding Tank present: (yes or no)_ Non-sa itary waste discharged to the Title 5 system: (yes or_no)_ Water eter readings, if available: Last to of occupancy: OT ER: (Describe) Last a of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: l S,' System pumped as part of inspection: (yes or no)�d If yes, volume pumped: gallons Reason for pumping: TYPE OF STEM 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. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: Ai S'S Sewage odors detected when arriving at.the site: (yes or no) �L O (revised 04/25/97) Page 5 of 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 212 Indian Trail Cummaquid. Owner: Stock Date of Inspection: B LDING SEWER: (Loc to on site plan) Dept below grade: Materi I of construction: _cast iron _40 PVC_other (explain) Dista ce from private water supply well or suction line Diam ter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:_✓ (locate on site plan) Depth below grade: Material of construction: /concrete _metal _Fiberglass _Polyethylene —other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) `Dimensions: � `x Sludge depth:/ 3�, Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: /•-;L ,• t't Distance from top of scum to top of outlet tee or baffler Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: 2•a Comments: (recommendation for pumping, condition of inlet and outlet t es or baffles, de th of(i uid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) GREAS TRAP: (locate o site plan) Depth be ow grade: Material f construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensi ns: Scum th ckness: Distanc from top of scum to top of outlet tee or baffle: Distan from bottom of scum to bottom of outlet tee or baffle: Date last pumping: Comm nts: (recom endation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integri , evidence of leakage, etc.) (revised 04/25/97) Page 6 of 10 . j SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 212 Indian, Trail Cummaquid. Owner: Stock w Date of Inspection: TIGH OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) ' (locate n site plan) Depth E elow grade: Material of construction: _concrete _metal Fiberglass _Polyethylene._other(explain) r Dimen ions: Capac gallons Desi flow: gallons/day Alar level: Alarm in working order Yes; _ No Dat of previous pumping: Com ents: (cond tic of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:— (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal,evdVl;ce of solids carryover, evidence of leakage into or out of box, etc.) PUMP HAMBER:_ (locate n site plan) Pumps i working order: (Yes or No) Alarms n working order (Yes or No) Comm ts: (note c ndition of pump chamber, condition_of pumps and appurtenances, etc.) (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM • ` PART C SYSTEM INFORMATION (continued) Property Address: 212 Indian Trail Cummaquid. Owner: Stock Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not 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: Alternative system: Name of Technology: Comments: (note condition of soil,.signs of hydraulic failure, level of ponding, randition of vegetation, etc.) / YZ CESSP OLS: _ (locate site plan) Number nd configuration Depth-to of liquid to inlet invert: Depth of olids layer: Depth of cum layer: Dimensio s of cesspool: Materials of construction: Indicatio of groundwater: inflow (cesspool must be pumped as part of inspection) Com ents: (not condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate o site plan) Materials of construction Dimensions: Depth of solids Commen s: (note co dition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (zeviaad 04/25/97) Page 8 of 10 f ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 212 Indian Trail Cummaquid. Owner: Stock Date of Inspection: ��r j�1� FIT- SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 1 39 , i 1 . (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 212 Indian Trail Cummaquid. _ Stock Owner: Date of Inspection: x• • Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record v Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) (revised 04/25/97) Page 10 of 10 No.- ._.. FRi&.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEA TH oF.......................... %L-- . pphratioo -for ligpoottl Workii Tattitrurtion Vrrotit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System t ............__•Z __' _•---•---••.••• ......................................................... Locatio dress or Lot No. ° .................................... ............ ' ner a Address W Installer Address Q Type of Buildin Size Lot............................Sq. feet U� Dwelling No. of Bedrooms.......... ... ___________________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) P4 Other fixtures _______________ W Design Flow_ __________________ _ ___ tllons per person per day. Total daily flow------- __._.._..._.__.._.._._-..-gallons. WSeptic Tank T Liquid capacit llons Length________________ Width................ Diameter---------------- Depth----------_--- Disposalx Trench—No. .................... WidthYin _... tal q .... ........... Total leachingarea.............. ft. �� � 1" q Seepage Pit No._ .._.____.. Diameter .... _ Depth e ow t et....` __.._._••- Tot 1 leachi area______ _____ ___sq. ftOther Distribution box ( a ) Dog tank ( ) C /6�2 7�� aPercolation Test Results Performed by.......................................................................... Date........................ ------------- Test Pit No. I________________minutes per inch Depth of "Pest Pit.................... Depth to ground water.-..___.-____.____.___-- (7, Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water-....._---___-_____..__. a •.............•...----- ------------- _......... •---------•---•-----_-•--------- Description of Soil------------------ ---------------• did', � r -- -..�� V..� x W ------------------------------------------------------------- .........................................--- ------- - n VNat e of`Repairs or Iterations— n er when a icable..`�.. _ r ��... _�-___ _{l��Y'`^�-��'. _. _ -/-fib- _ f.� - ._ _ u Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i4sued by the oar of h Ith. igned---- - -- --- ---------------------------- -------------------------------- Date Application Approved By------- - ----- --- ---- - = ------ 7_3------------- Date Application Disapproved for the following reasons:--•-••-----•.................••••--•-••••--•---•-•-•-•-••---••--......_..------------•-•---•----•.._...... •••••--Date. Permit No.---------•-••-•---•••--•------•----••-•---•••---......_. Issued. .�� te.7 .... Date No. `... .......... .................. THE COMMONWEALTH OF MASSACHUSETTS _ BOARD, F HEA TH I�. , - ......OF......... ........... .: ............. � Applirtttiutt -fur Miivoottl Works Tomitrttrtiott Vanttit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal SystemZ" t , ------ er4,........................................................ �Locationy(Q,ddress or Lot No. yc ncr Address (/ Installer Address d Type of Buildin Size Lot............................Sq. feet Dwelling No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ________________________ _ No. of persons---------------------------- Showers ( ) = Cafeteria ( ) a' Other fixtures -------------------------------- - ----------------- Design Flow_ ____________ _ ----------gallonsperpersonperday. daily P P P Y• Y �--=-------------------------gallons. WSeptic Tank L Liquid capacit �gallons Length................ Width................ Diameter---------------- Depth............. x Disposal Trench—No. .................... Width,_: otal� ery '-----.------------- Total leaching area........------------sq. ft. Seepage Pit No.. ------____-- Diameter - ---- -------- Dptfi el`owC'i et �- ------.---- Tot 1 leach' trea-------.----:----sq. ft. Other Distribution box Dosingtank Jc �� Percolation Test Results Performed by-------------------------------------------------------------------------- Date---------------------------------------- aa Test Pit No. I................minutes per inch Depth of "Pest Pit............._...... Depth to ground water..-..._-..-------------- G%, Test Pit No. 2................minutes per inch Depth of Test Pit._-__-___..------__- Depth to ground water-----.---__-.--.-___--. ----------------------- ------ r l D Description of Soil--------------------------------------F -/ d e-�- -w.... Cr-drr..f-y--- --f- ----------' V ....................................... .........._.. ------- -- ----- ---;-------------------._.._.._.._.. --------- - -----------------------------------------�Iterations -------- ----• G -r` ._-------- - ----------- U Na e of Repairs or —An er when yap icable-------_ _ _ .. . ...... ..... .tea... __. ....... �� .`... ... , - ---- ---�� 1�'G--- --- Agreement: �C/The undersigned agrees to install the aforedescribed Individual Sewage Disposal System'in accordance with the provisions of Article XI of the State Sanitary 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. igned- n.� Cp�' fr. t' ail ----------------- Date Application Approved BY--- - .` ----- - . ---7.� ------------- Date Application Disapproved for the following reasons------------------------------------------------------------------------------------------------------------•---- ••-••--•••---•---•--------------•---•-•--••--•------------------•-......-•-•••-••--•-•----••-----••--•------•-•••••-•------•----•-••----------••••••----•-•----•--------•..._........---•-•----•--•-•--. Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 14, 5� 1`et,-' -r.. OF.............. ...... .. ................... Trr#if irtttle of 'T'llmlitttta T IS IS TO CERTIF That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) /.,,r at---- --- ..!�t.�': 1------------ -- -------•----•--•------------------------- has been installed in accordance with the provisions of Article XI of The State Sanitary Cod as described in the application for Disposal Works Construction Permit No___________ ____`�.'._ ............._. dated....��1_rf..7_--�_................. THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM Vd,ALLv FUNCTION SATISFACTORY. DATE ------ Inspector. THE COMMONWEALTH OF MASSACHUSETTS a BOARD��F HEALTH s^ rr"^ ................OF........... ��•....a...........---........----.............-----... �-.... No.----= ....--/------ FEE urkii Tlowit Mott Vrrtttit j �_ Permission s ereby granted..:"--- _ L �2 = to Constru,t (!_) orLepair ( ) an In i Idu gwage Did? . 1 Sys f ..t '-at No. Q ---- '. � e«s .. --- �t. ..?�.' Street as shown on the application for Disposal Works Construction Permit No--------------------- Dated.-----f//- f��.____.__. -- Board of IIealtho DATE.`.. --••- F d'" ----• /';. o 4.� s FORM 1255 �OBBS &'WARREN. INC.. PUBLISHERS rY a P i I 3 n.