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HomeMy WebLinkAbout2150 MAIN ST./RTE 6A(BARN.) - Health 2150 Main StreeVRte 6A (Barn) Barnstable A 237 007 Ll II! i� o c � a i oi A&A C"141 f 10 , tic Of PTO " ANN M in L AST RY INS F f } ¢ 1 x• x s e. F - Y'fk" r a& ` > 2 � � ♦i �4 kt, �b'yri'S i foil- lot,�Afjv $ Y one 1 'w �} l , t aA ismss r t, COMMONWEALTH-OF MASSACHUSETTS _ f EXECUTIVE OFFICE OF ENVIRONTME-IVTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION n •s e TITLE`5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL,SYSTEM FORM . PART A `7 OUo-J. CERTIFICATIOIN Property Addres s: Owner's Name: L]Owner's Addres , Date of Inspection: p Name of Inspector• (pi ase rint) Company Name: t ,KS�tevtcond "' Mailing Address: Telephone Number: + C", c xi - - CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the inforfittation reported below is true,accurate and complete as of the time of the inspection. The inspection was performed�j 11ased on training and experience in the proper function and maintenance of on site sewage disposal systems. Ilam a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails , Inspector's Signature: Date: 6 The system inspector shall submifa copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 t page I Page 2 of I I OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM t PART'A CERTIFICATION(continued) Property Address: r'l � g S�� /7 Owner: A Al Date of Inspection: d 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 C M 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Y I Comments: B. System Conditionally Passes: One or more system components as described in the"Conditi 1 Pass"section need to be replaced or repaired.The system,upon completion of the replacement or reps' ,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the r the following statements.If"not determined"please explain. The septic tank is metal and over 20 years d*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or a ation or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying s tic tank as approved by the Board of Health. *A metal septic tank will pass inspection it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 ars old is available. ND explain: Observation of sewag ackup or break out or High static water level in the distribution box due to broken or obstructed pipe(s)or due to broken,settled or uneven distribution box. System will pass inspection if(with. approval of Board of He h): broken pipe(s)are replaced obstruction is.rsmoved- distribution box is leveled or replaced F ND explain: Th system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspe tion if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: . R Page 3 of 1 I OFFICIAL INSPECTION FORM- NOT FOR,VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: �(r ftee _ Owner: Date of Inspection: 6 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of ealth 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 cordance with 310 CMR 15.303(l)(b)that the system is not functioning in a manner which will pro ct public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surfac ater _ Cesspool or privy is within 50 feet of a bord g vegetated wetland or a salt marsh 2. System will fail unless the Board o ealth (and Public Water Supplier,if any) determines that the system is functioning in a manner th protects the public health,safety and environment: _ The system has a septic and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tribut to a surface water supply. — The system has a se is tank and SAS and the SAS is within a Zone I of a public water supply. The system has eptic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system h s a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a ' private water sup ly well". Method used to determine distance "This syste passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and olatile organic compounds indicates that the well is free from pollution from that facility and the presenc of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure cr eria are triggered.A copy of the analysis must be attached to this form. 3. Ot er: y 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL-SYSTEM INSPECTION FORM, PA.RT.A= , CERTIFICATION(continued). Property Address: oZ15D & R Owner Date of Inspection: 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 Required pumping more than 4 times in the last year NOT due to clogged.or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 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 analy*..(This system passes if the well water.analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic,componnds 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.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure: E. Large Systems: To be considered a large system the system must serve-a facility with design flow of 10,000 gpd to 15,000 gpd- You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in.addition to the eria above) yes no the system is within 400 feet of a surface dr' g water supply the system is within 200 feet of a tributary a surface drinking water supply _ the system is located in a nitrogen sens' ve 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' Section E the system is considered a significant threat,or answered "yes"in Section D above the large system as failed.The owner or operator of any large system considered a. significant threat under Section E or fail under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should c ct the appropriate regional office of the Department. . Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .PART B CHECKLIST , Property Address: i h Si Ced Owner: TbVun e S Date of Inspection: 6 zilph . Check if the following have been done.You must indicate`yes"or"no"as to each of the following: Yes No _ Pumping information was provided by the owner,occupant, or Board of Health (. Were any of the system components pumped out in the previous two weeks? . _ Has the system received normal flows in the previous two week period ) Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of breakout? Were all system components,excluding the SAS,located on site?. :0 _ 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 _ Existing information.For example,a plan at the Board of Health. Ot _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [31.0 CMR 15302(3)(b)] Page 6 of 1 1 OFFICIAL INSP]EICTION FORM'-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 0/ 'D A&i ra ml?cf Owner:��Lw �� Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Y Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for,example: 1 10 gpd x#of bedrooms): qro Number of current residents: Does residence have a garbage grinder(yes onno):AVi Is laundry on a separate sewage system (yes or no):g�Z [if yes separate inspection required] Laundry system inspected((d�e,s or no): Seasonal use: (yes or no):% Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no):1144 Last date of occupancy: COMMERCIALIINDUSTRIAL Type of establishment: _ Design flow(based on 310 CMR 15. gpd Basis of design-flow(seats/perso sgft,etc.)- Grease trap present(yes or n ._ Industrial waste holding present(yes or no): Non-sanitary waste di arged to the Title 5 system(yes or no):_ Water meter read ,if available: Last dat7escribe): ancy/use: OTHE GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): If yes,volume pumped:_gallons-- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/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): Q Approximate age of all components,date instal le (if known)and source of information: Were sewage odors detected when arriving at the site(yes or no):J Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) r* Property Address: ( m t ,, 61 f Cef . Owner: -6,r,V Date of Inspection: p6 BUILDING SEWER(locate on site plan)tA ` Depth below grade: _ Materials of construction:_cast iron V 40 PVC other(explain): Distance from private water supply well or suction line: , Comments (on condition of joints, venting, evidence of leakage,etc.): ` SEPTIC TANK: (�(locate on site plan) Depth below grade: _ Material of construction:�( concrete_metal fberglass Polyethylene —other(explain) _ If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Z" " Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee$r baffle: Ib� How were dimensions determined: ���riCX a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels " as related to outlet invert,evidence of leakage, etc.): ` - lA, GREASE TRAP:_(locate on site plan) r t Depth below grade: Material of construction:_concrete metal fiberglass_polyethylene'_other (explain): — Dimensions: *, Scum thickness: Distance from top of scum top of outlet tee"or baffle: . ` Distance from bottom of um to bottom of outlet tee or baffle: Date of last pumping: Comments(on pump' g recommendations, inlet and outlei tee or baffle condition, structura],integrity,liquid levels ' as related to outlet ' vert,evidence of leakage, etc.). Page 8 of i 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) , Property Address: 1 s f Owner T u►�n i Date of Inspection: TIGHT or HOLDING TANK: (tank must be pumped at t" f inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: >no): gallo Design Flow: ons/day . Alarm present(yAlarm level: n working order(yes or no): Date of last pumComments(condand float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 2V44.4 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leaka a into or out of box,etc.): II L+ 0_ �nA CAL rV%4 PUMP CHAMBER: (locate on 5ite plan) Pumps in working order( or no):. Alarms in working or (yes or no): Comments(note c ition of pump chamber,condition of pumps and appurtenances,etc.): . f 8 Page 9 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY,ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ( � atro`rt _ f e Owner: KlL1 e S� Date of Inspection: ��—y 26 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 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.): I S 5� kp-V U 6 &L 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 laver: Depth of scum layer: Dimensions of cesspool: Materials of constr/ion Indication of grounw(yes or no): Comments(note coil,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 conditi of soil,signs of hydraulic failure; level of ponding, condition of vegetation; etc.): „ 9 Page 10 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_� ( 'a 1r>! Owner: �ohwi Date of Inspection: b 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 Page I I of I I OFFICIAL INSPECTION FORM—jNOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ISO ��S�rce( ' Owner: 16lA i S Date of Inspection: SITE EXAM Slope Surface water Check cellar �Qfi Shallow wells Estimated depth to ground water_,26�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 dense how you established the high ground water e1e ation: l � • 11 y TOWN OF BARNSTABLE I` LOCA ON d al So mnIN Sf- �r��WT SEWAGE #v2Dc�"v'Z- ®q VILLAGE 13A2A1 S E 664-C- ASSESSOR'S MAP & LOT ,237 007 INSTALLER'S NAME & PHONE NO. 6GL 5 91?,v5 - C6rv57' 5-o,9-3a-(vA37 SEPTIC TANK CAPACITY �o v i r LEACHING FACILITY:(type) Sba 6;'-C*ygfzj (size) NO. OF BEDROOMS S PRIVATE WELL OR PUBLIC WATERA/60G- BUILDER OR 4,V o4..PH DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No C- 3 IjT- No. '� �L Fee•.�C � ` THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: s `> PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2pplication for Migogar Op�tem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) O Complete System O Individual Components Location Address or Lo No. Owner's Name,Address and Tel.No. A m u!n S Viable �dn c�S V i Y A i`i 11.* d L h As 007 Xi s in i h oi- IV. 6.9 la )-r Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. P. 43/b1X•rf cb.,.r3 • co 00&.4 L Cq. Type of Buildin . Dwelling No.of Bedrooms Lot Size P 7eV7 sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Set Sv,"1 L 6 Nature of Repairs or Alterations(Answer when applicable) S rP 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 f the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b is iRo ofMal Signed Dat/������— Application Approved b Date /��' �6�"Zf Application Disapproved for the following reasons Permit No. , 9 ;Z a 6o�l Date Issued -- -I .w...,� -/"� wYn1 Ir. •V'MR'�k1i''.i4�i,.{'wn.+M., . • ' } _4 <: No. 5/!/G, �( �* .. Fee � THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: - :� '- PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0(pplication for Mi5poear *pgtern Construction 3dermit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) O Complete System El Individual Components Location Address or Lo4 No. a � Owner's Name,Address and Tel.No. s lr fi�R S .S44& @ Ass ys ap/Rsrc'4e1� 7 Uc 1 SC, I,,. ;-7J/? � 3 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. i` /3o-,/-�,c f c-c r,S) - cc IJC� ✓� C�,�, r d31-7n �ec < Type of Buildin K Dwelling No.of Bedrooms Lot Size ,a 7y7 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) - Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil S n P Sc, I Nature of Repairs or Alterations(Answer when applicable) n } 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 f the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b is Bo of al Signed Dat/_�S U� Application Approved b Date Application Disapproved for the following reasons Permit No. .20z:2�2i644-�- Date Issued---------------------------------------- _ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( ) Repaired( )Upgraded( ) Abandoned( )by at ,mac) ky)ti,n Sf R r 6 t9 k/ PSj- (2 s In 63Jy has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit T�?Od .. l i dated Installer _ 1 i i S r:j Designer CT— The issuance of this permit shall not be construed as a guarantee that the system .ill function as desig e _ Date Z )A Inspector A-4 d � t 1 i-- �,,-U r' _— No./iy�2 .�f`�/� ------- ----------------Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS 'Wi5po5ar *pgtem Construction 3permit Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( ) System located at 'a I S4 /-)-1,,7 S1 1' ���; �q, sJ- 6,5-(n �,Jr7 63/f i and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of thi ermit. Date: �"r �_ / elZ Approved Y TOWN OF BARNSTABLE LOCATION l 570 M141N ST PT6-66 SEWAGE # ,�200,-�_ ®�f VILLAGE etv, 13A(ZA)S7146ec ASSESSOR'S MAP & LOT o237 007 INSTALLER'S NAME & PHONE NO. j5 lJ5 glge5 - CeivSl S'o,9-3Q-6A37 SEPTIC TANK CAPACITY / r&O LEACHING.FACILITY:(type) 57 5-66 d;f-C114N&L) (size) NO. OF BEDROOMS S PRIVATE WELL OR PUBLIC WATER6p(/6L/G- BUILDER OR At 1)4J & AIbOi— DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: J.� VARIANCE GRANT D• ' No � Jr" r",j j OET�: 6.4 -------� COMMONWEALTH OF MASSA.CHUSETTS 01 MW EXECUTIVE OFFICE OF ENVIRONMENTAL AXFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION r Zo2� MIE 5 OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSM iTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A.. CERTIFICATION ; Property Address:aun �11►CyS �T. .. t �ECEwVE® Owner's Name: Nhra jA pua4r4, NOV Owner's Address: x. i-xic%-'z�� a(�� *` OF BARNSTABLE Date of Inspection: oCi 1 DAL TOWHEALTH DEPT. y . RE ID D C. ELL- Name of Inspector. L 8 l I S Company Name. - 3 EXTERRRISE ROAD P.A, y Mani Address: 2 "` BOXN 59 YAR14Ul1TN -.PQRT, MA ' . Telephone Number-- K 8-362-6237` ` JL� 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 twining and experience m theproper filmon and maintenance of on site sewage disposal systems.I am a DEP appro"d system inspector purr met to salon 15340 of Title 5(310 CMR 15.000) The system: . 0 Passes Co '011ditionallyPasses: f. eels Further Evahtatiori by the Local Approving Au wity e. , Inspector's Signature. _ G-, L.— MDate:°, .L7•=-,�C� The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of co,"Jeting this bspec don.If the system is a shared system or,has a design flow of 10,000 gpd or greater,the inspect and the system owner shall submit the report to the appropriate regional office of the DEP•'the should be Ott to the system owner and copies sent to the buyer,if applicable,and the approving authority. r } s - Hotta and Cvn meats y .. - r= ****Thy report only d it�n at tTi�of's the s time.This� tn pgction and tinder the eaaditit►As of at that condaaians of um iQ D°doe coal addrm 4ow the systmem will perform in the future under the same or different M :. - •. 5 - Title 5 Inspetxion Form 6JISI2000 page 1 Page 2 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) ' Property Address: dl i S YYIA\ ��p _ Owner: V iY i AM ; Date of Ins tion: i 10- 0 i Inspection Summary: Check A,B,C,D or E I WAYS com 1etp all of Section D A. system> - I have not found any information which indicates any of the faihue criteria described in 310 Chin 15.303 or in 310 CMR 15.304 exist.Any failure criteria evaluated ate indicated below. Comments: B. System Conditionally Passes: One or more system components as described_' the"Conditional Pass"section need to be replaced or repaired The system,upon completion of the replace t or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,NND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*i r the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or ex&ltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank approved by the Board of Health. 'A metal septic tank will pass kspection if it is souctui ft sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is avail ble. ND explain: Observation of sewage backup or break out or h static water level in the distribution box due to broken or Obstructed pipe(s)or due to a broken,settled or uneven fistribution box.System will pass inspection if(with- approval of Board of Health): broken pipe(s)we vplaced obstruction is renic ved distribution box is eveled or replaced ND explain: The system required pumping more than 41imes a pas inspection if(with y�due to broken or obstructed pipe(s).The system will s approval of the Board of Health broken pipe(s)are n phced obstruction is rernov W - ND explain: Page 3 of 11 ` OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address. :,1 f QT CA UL Owner:�1]to�ri►� R At Date of luspaction: It, o--a i /V C. Further Evaluation is Required by the Board of H Ith: Conditions exist which require further evaluation b the Board of Health in order to determine if the system is failing to protect public health,safety or the environment I. System will pass unless Board of Health determij es in accordance with 310 CMR 15303(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 tea of a surface water Cesspool or privy is within 50 feet of a borderi og vegetated wetland or a salt marsh I 2. System will fail unless the Board of Heal4waw We Water Supplier,if any)determines that the system is functioning in a manner that proteile health,safety and environment: _ The system has a septic tank aril soil aystem(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surfacpPly- _••_ 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 AS is within-50 feet of a private'water supply well. _ The system has a septic tank and SAS and the 3AS is less than 100'feet but 50 feet or more from a Private water supply well*".Method used to deten ine distance *"This system passes if the well water analysis,pei Ruined at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates t tat 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- I Other: >: . p Page 4 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continual) Property Address:L�� t� ., ttob d Owner: Date of 'on. A 0- c D. System Failure Criteria applicable to all systems: You F—M indicate"yes"or"tm"to each of the following for Airmections: Y 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 surfac clogged SAS or cesspool e waters due to an overloaded or Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ iquid depth in cesspool is less than V below invert or available volume is Iess than%day flow -- Afeclubred Pumping more than 4times in the last NC) du year_� a t4 el or obstructed i s .Number times pumped �� is PeL ) _ Any portion of the SAS,cesspool or privy is below high ground water elevation. y portion of cesspool or privy is within 100 feet of a surf ere water supply or tributary to a surface �PIY y 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.(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 a d nitrate nitrogen is equal to or less than 5.ppm,provided that no other failure criteria are ' �GA copy of the analysis must be attach to this form.} es/No) system f IL 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 the failure. r & LaW Systems: To be considered a large system the system row t serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"nq"to each of I 3e following: (The following criteria apply to large systems in dition to the criteria above) yes no the system is within 400 fat of a suifact drinking water supply the system is within 200 feet of a tributm y to a surface drinking water supply the system is located in a nitro gm Sens' we area(Interim Wellhead Protection Area—IWPA) Zone lI of a public water supply well ' or a mapped If you have answered'byes"to any question inSeaon E the s ` "yes"inSection D above the ystem is considered a significantihreat,or answered significant threat and �a system has fail The owner or operator of any large system considered a et Season.E or failed under Section D shall upgrade the system in. t s 3oa.The system ow=w should contact the appropriate reg and offi accordance with 310 CAgR ce of the Department Prop=q Address: Qjgt) msa� 13_ Wl r Owner:_� Date of Ins lion: 1 O-••1 e1Q 1 Check if the following have been done_You must indicate"yes"or"rW'as to each of the following: Ye No umping information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeks? �/as the system received normal flows in the previous two week period? _/iiave 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 NIA) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs ofbrcak out`' 4 Were all system components,�acluding the SAS,located on site 1Y�_ Were theqWcPmk manholes uncovered,opened,and the interior of the tank inspected for the condition 7a�as ortees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? the facility oxOrter(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? a ize and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no Existing information.For example,a plan at the Board of Health. _ Determined in the field(if any of the faihrre criteria related to Part C is at issue approximation of distance is unacceptable)[310 CUR 15302(3)(b)j i ® - e Page 6 of I I ' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION ` Property Address: al�50 IYIgi►n Q ,(r J) Owner: V 1 Irg i Y1 Q , Date of n:_ i 0ri0-1a i FLOW CONDITIONS - RESIDENTIAL Number of bedrooms(design) Number of bedrooms(actual): DESIGN flow based on 310 CMI�15203(for example: 110 gpd x#of bedrooms): - Number of current resides: / Does residence have a garbage grinder(yes or no): e✓ ` is laundry sewage system ar no):� �fYes separate La system or no): / 1 Av j a _9 Seasonal use:(yes or no)- Water meter readings,if -la leW T ��� Sump pump(yes or no): /t7 Last date of occupancy: COMMERCIALIMUSTRIAL Type of establishment Design flow(based on 310 CMR 15203): _ Basis of design flow(seats/petmonVsgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ • . Non-sanitary waste discharged to the Title 5 system(ye or no): Water meter readings,if available: - Last date of occupancy/use: OTHER(describe): - 0 GENERAL INFORMATION Pumping Records Source of information Was system pumped as part of the i ectionyes or no): /� - If yes,volume purnpe! ons-How was quart` determined? Reason for pumping: 7.-Q. TYPE OF SYSTEM R epdc tank,distribution box,soil absorption system gle cesspool µ Overflow c:esspoo! Privy } ___._Shared system(yes or no)(if yes,attach previous inspection records,if any) InnovativclAiteraat;"e tect6rolagy.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 f _ —Other(describe): _ Approxim F age of 1 co en mpg �,d�temalted(if known)and source of jnfo lion: ®1� Were sewage odors detected when arriving at the site(yes or no): f Page 7 of l 1 OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued); Property Address: IiQ llflA } ) �iRYnS��j�C��ablo� Owner: {� Date of I n. '4 t Q L i BUIIAING SEWER(locate on site plan) Depth below grade: k Materials of construction: cast iron PVC—"Odw(expiam�n): Distance from private water supply well or suction line: Co ents V n copditian qfjoints,ven M,c f leakage, ): SEPTIC TANK: `(locate on siteplan)' Depth below grade: Material of construction:_concrete metal fibergl polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certific ite of Compliance(yes or no):_(attach a copy of certificate) ` Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom ofoudet tee or How were dimensions determined: Comments(on pumping recommendations,inlet and outlet or baffle.condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage, /v , GREASE TRAP: (locate on site plan) # Depth below grade:_ Material of construction: concrrte metal: fm r polyethylene other - (explain): Dimensions: Scum thickness: Distance from top of scums to topof outlet tee or baffle: Distance from bottom of scum to bottom of outlet we or baffi Date of last pumping: Comments(on pumping recommmlatiomas,inlet and outlet tc or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): t. . f rag¢oLa is OFFICIAL:INSPECTION FORM-=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM=LNSPECTION FORM. PART C , SYSTEM INFORMATION(contini ed). Property Address: al'50 ►Y► T,&A Owner. Yini'MIA L?ftV%C61j26 _ Date of Inspection: -1 Q-t PowTIGHT or HOLDING TANK: (tankmust be pumped of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal ° 5berid _polyethylene other(explain): Dimensions: Capacity- Design Flow: galIons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): x. Date of last pumping: -Comments(condition of alarm and float switches,etc.): - DISTRIBUTION BOX: (if present must be opened}( Cate on site plan} Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets eq xd,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): a Comments(note condition of pump chamber,condition ol pumps and appuitenances,:etc.): " { Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR'VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM IlYFORMATION(continued) Property Address• 1 RT,�nA Owner:yit A n�1� Data of Inspon: 10 1 O-e i SOIL ABSORPTION SYSTEM(SAS): ovate on site plan,excavation not required] _f If SAS not located explain why 1 - Type ., leaching pits,number_ rt leaching chambers,number: leaching galleries,number: leaching trenches,number,length: r leaching fields,number,dimensions: �fov w ` erflo cesspool,member.� innovative/alternative system Typefname of technology: Continents(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc. �� • ow 4KV�r CESSPOOLS: cesspool must be plumped as part of inspectionxlocate on site plan) Number and configuration: _ Depth—top of liquid to inlet Nyl b y Depth of solids layer: d Pew ! :' Depth of scum layer Dimensions of cesspool: , Materials of construction: M Indication of groundwater inflow(yes or no)s.4JV 'q Comm=%(ucVmdyion of soil,signs cOrydrdalic fat m,levee of pending,condition f vegetate etc.): op 0y Ciez PRIVY: (locate on site plan) Materials of construction: « � . Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic fail ,level of ponding,condition of vegetation,etc.):.," Page 10 of 11 a ' OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION DORM PART C SYSTEM INFORMATION(continued) • .,t 1/ c .. 1�wf1 - Property Address: p r, Owner. Date of Ins ion: 1 p-10--a 1 F ' K6� y{+ l* r•.r del ,. f a k;� r, -SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch ate sewage disposal system including ties to at least two'permavent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building: : tt • i c` o- i xy r ,�{ LR ",. '° *' 3 4 s , 4 J♦ M 3 !A6 -f Ye It -All t {^ Al .. ,. i .mow • .. R. Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued). Property Address: to -w Owner. Date of n• l SITE EXAM Slope klxl� Surface water Check cellar Shallow wells Estimated depth to ground water -- feeY _ s 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 praperry/Observation hole within 150 feet of SAS) Lkdwith local Biocal exA USGS database You must descqbe how yo established the high nd ater elevation:• I q SYSTEM PROFILE TEST HOLE LOGS TOP FNDN, AT EL. 79.6' - _ C.I. ACCESS COVER TO GRADE (NOT TO SCALE) ACCESS COVER (WATERTIGHT) TO ENGINEER: ARNE H. OJALA, PE 77.5' MINIMUM .75' OF COVER OVER PRECAST /� WITHIN 6' OF FIN. GRADE 2% SLOPE REQUIRED OVER SYSTEM WITNESS DAVID STANTON , 2' DOUBLE WASHED PEASTON DATE: 11/14/01 t 'I` RUN PIPE LEVEL 76.0'1 FOR FIRST 2' 3' MAX. PERC. RATE < 2 MIN/INCH A r :RED1500 a a 75 25' N SEPTIC 75.0' / H-10 CHAMBERS 75 0� 10,104 CLASS I SOILS P# H- 20 ) GAS 74,18' CI Q Cl Cl 0 !� 0 CO C7 'A OAK " o BAFFL 74.35' �" Q 74.17' 0 CJ CO 0 © M 0 E7 ED ` 3' AT SIDES a ROUTE 6A MIN M Q CO ED M = C7 CI C] Q ELEV. Q ELEV, Locus 2 6" CRUSHED STONE OR MECHANICALa ( % SLOPE) DEPTH OF FLOW = 4' �^ �o8g 2' C� C� C] CJ 71 CJ O O o 72.17' 0� 78.0' `J 78_ _55' � * INVERT APPROX. ONLY. COMPACTION. (15,221 C2J) A CONFIRM FEASIBILITY PR TO TEE SITES ( 3 % SLOPE) < 1 % SLOPE) 3/4" TO 1 1/8" DOUBLE WASHED S I ,]NE SL 5L INSTALLATION OF ANY PORTION INLET DEPTH = 10 OF SEPTIC SYSTEM OUTLET DEPTH = 1 q„ 9" 1 OYR 4/3 1 OYR 4/3 11" FOUNDATION- 30' SEPTIC TANK 20' D' BOX 3' LEACHI"G B LOCATION MAP NTS FACT! Y! Y SL B 5.17 30" 2.5Y 4/4 SL ASSESSORS MAP 237 PARCEL 007 26" 2.5Y 4/4 Cl SL UNSUIT. Cl SL UNSUIT. 2.5Y 6/4 0 61" 73.4' 67.0' C2 ca 6 C2 6 FM S LOT AREA s a LFS STONES s 4 1$2,747t 5Q. FT. FIRM + sa.1 " 2.5Y 7/4 4.20E ACRES sA 2.5Y 7/4 100 60 s9 I C 3 6 6 \+ 58.7 I i F M S 6 1 159 I ? >, 2.5Y 7/4 66.0 64.16s 64 132" ' 67.0' 132 67.5' 1^, - 1 NO WATER. ENCOUNTERED NO WATER ENCOUNTERED 2 NOTES 0 \ APPROXIMATED FROM QUAD L DATUM IS -a + 6 3.2 SEP';�I f DCSIGk1 ,'',ARBAGE DISPOSER �s " A ( F .l _EXISTING�YP, I:�� a ' ' TER IS -DES. \ FLOW: :C _ r �. aITVIIM 0TRF " \ 5 USr E, 550 GPD '-ESI�--N FLOW _:. , __ PITL.,H Tf' RF 1/8 PFR FOOT. + 6 + 66.6 4, DESIGN LOADING FOR SEPTIC TANK TO BE AASHQ H- 20 66 6 SEPTIC TANK. 550 GPD ( 2 ) = 1100 S. PIPE JOINTS T❑ BE MADE WATERTIGHT, ____ 6.> 7 SE �. 1500 U GALLON SEP'IC TANK 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS. + 7 66 _ LEAC_IIING_. ENVIRONMENTAL CODE TITLE V. 68.5 2(47.5 + 10,83) 2 (.74) -- 172 7. THIS PLAN IS FOR PROPOSED SEPTIC SYSTEM ONLY AND IS NOT I 1 \ 69 671 SLIP.S: -- TO BE USED FOR ANY OTHER PURPOSE. 1 + 72.9 \ 47,5 x 10.$3 (.74) _ .SO 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. I � � 0.2 BE T T J M: 1 >, TE'T'A._; 746 SF. 552 GPD 9, COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED I } US._ (5) 500 GAL. LEACHING CHAMBERS (ACME OR FROM BOARD OF HEALTH, + 7 > - )110 EQUAt.) WITH 3 STONE AT Sir),E , 2.5' AT ENDS 10. PUMP & REMOVE (OR FILL W/CLEAN SAND) EXISTING SEPTIC SYSTEM rn CP J 71.9 �'��• + STO RET. 7A � ' I 75 70. 3.7 LEGEND 7,4 + 7�.8 TITLE 5 SITE PLAN 78--� 2 GARAGE 77 100A ; FROPOSED SPOT ELEVATION OF 4.0 2150 MAIN STREET ( ROUTE 6A) I I o" SPRU ,7-UC FLAG. PATIO 781 W 100x0 EXISTING SPOT ELEVATION 5' REMOVAL OF UNSUITABLE SOIL I R \ AROUND PERIMETER OF LEACHING I 6 SPRUC ---77*- ' 781 100 IN THE TOWN OF: PROPOSED CONTOUR ( WEST) BARNS TABLE FACILITY REQUIRED, DOWN TO I I rvT SUITABLE SOIL LAYER. REPLACE I I BAni WITH CLEAN MED. SAND. ENGINEER 17 I TT L._._.I EXIST. , 100 ExISTING CONTOUR PREPARED FOR: VIRGIN(A R AN D O LP H TO INSPECT AND CERTIFY REMOVAL j I SHELL I DWELLING s I I I DRIVE I 77.6 7-7-.3- 4 7 I 77.5119 ( + 7 7 30 0 30 60 90 I I I � 76.9 76 BOF,RD OF EA.LTH I UTIL + 6 �$I� I B I I I ',-i _ _ MA SCALE: 1" = 30' T POLE APPROVED DATE DATE: NOVEMBER 15, 2001 T off fax 508Y362-4541 362-9880 1 I e C 9 +1 163.58' > OF I O I ASH Mq I + 80.9 q .7 �� �lA01Al 8 80.0 _ _ _ _ __ _ - 78.6 ze GlOWn cape engineering, Inc, AWAY ��� ARNE���� - CIVIL ENGINEERS CIVIL H. s BENCH MARK - TOP OF WATER 3(7792 3 <MA ROUTE 6A SHUT OFF VALVE EL.= 78.9 (ASSMD) LAND SURVEYORS ,STV o O'26 939, main st, yarmQuth, r,a 02675 A OJALA, S. DATA