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0165 MIDPINE RD - Health
165 MIDPINE ROAD, BARNSTABLE A= 356 014 - - ,4 ° .. .. -l-- iE r o. C/ l I ' Land \ M1Y, Nnw � h - �'�T r , • -1 I . __ - � � is --••------ � a. � , - w I` �' t' t - u _77 1 - Y _ + L _ 1 _ Z a awa, PAR A. i t 1 I ' I , 4i aaw: a ,..•. ,n:�- - .._ ,h. -„r t,: . `- _,a:- '-�.-vae... .� ���.' �,-.-,..-•�-._::.:--_,�..:. .+x,.�.» _,�-.;.-3:'�-•:�m.+tns -.-s•st,.�ucv�c.3,...��s.+.: �'•x`i:'�-s�-� - ..aw"' -�.�L..-.»., -�-�-..:.•.a..._._..3,tip- �, �-:.,.,.._...--,-.....-.. ._3stx,3.�.�.a`a..3�. ,..-�...-.., �_ -,...i: •'------'—."__ ._„ , :. -_• _-.....' .. �- �" ;- •-_._-« it I --._ ..' �t — - -- -- - ----_ s...,u,.c, r•)_ - T .0 _ __ _. — - ..:,..,._-}...:< ,...... r.._...ask. .1_ U.. -x. ... ,..,. ..-..: .. 4 _ it•L��.a'.?,;�. >�.:.;•; •„a ��-. ,&.I ,.T EMP �. .»-:�,,.�z-. ._gym -T . .:- _. _� .a.>.,.,.� ...� n.-s_. .•.�...-�1 «-„^-'f:.•'_ .^`=--_' d•4.- r t -'er.+rirc. �t I• -1 + - i FtWNIT .___..,n�^T .•.y.,... ,,. � s.. `f-- .. ,__ .,-..•,. ,. _._.r.- > .. _ .-c`-�_-._... _. +rt-: _ n.a.r._ -a.,�..r^-T'I .... - Y.ao>♦ tit` e�i..._a._ '_'N;�_ --"`>•, II_ - _ . - - _ _"_..T--t>•_ _.. _. _"...- ..«v- - _... ,.:.... __ ,. - - ,( '- •'� _- it �- - _.�. _.. - - _ CUrY,w - �tnNls ww✓ (.�f ..: --.- :1wVd1,V__. IE E 1 �+ �e:nrK.. �E� •WNt C2.r:mi--�;� ;1 - III ±'�_l _. • I . __. : ... 71t xK" ,N .a'h.t•,Y: EtizLRV,o 9A»ti^e+d.L Mw# ^A�'M I•nv:!.�..uw iG - ^•-�... � '[/$/M'�/��__ Fif9.\.e, ■> ,-n0. .,,i 4.,c.>)Sn.,a�:,-r.tab I�:NO,acG) �i ..- -- '• •-' ' �WuT;,(rq...,M17:.:t:t:'rz�'fT."YCP:Z pJiy Si'JH•�a BFlrv,�yc ..A,cr•..>s) �-Y6<pf ./itp9rrrw AD tah-r•ya:::� tSf4 ti GIr/ TOWN OF BARNSTABLE ® e Co LOCATION 4-1' Q k SEWAGE # 0U— V �/1l�LAGE "a '`' J1 �� ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 9 dr. 1.. L (size) e'` 'V NO.OF BEDROOMS � `/ ' .5 G v n BUILDER OR OWNER ,<�7-A PERMIT DATE: g 0 COMPLIANCE DATE: S ®-e" 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 .' �1 ; Z a a TOWN OF BARNSTABLE 'LOCATION f i h c g SEWAGE # Vr,iLAGE C✓Y6011414 y u. 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 and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by �S PL 38 ' cz� TOWN OF BARNSTABLE I1LOCATION � ��C �►CI.QcnQ, KC—k SEWAGE # ''"PILLAGE y►n(` Gj �` ASSESSOR'S MAP & LOT :3;r:4a( `o1 q INSTALLER'S NAME Cz PHONE NO. '. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: k DATE COLIPLIANCE ISSUED: `VARIANCE GRANTED: Yes No f } ��� 6�� P 3 � (v'� Y � � �: a rNo. - '# y FeA 5 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0[ppfication forbiqual *pgtem Construction Permit Application for a Permit to Construct( )Repair V, )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. AsAlr' /Pa�c�ne Rd _C�t quid Nelson Knapp Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service P O Box 1089, Centerville Type of Building: Dwelling No.of Bedrooms 4 Lot Size 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 Sand Nature of Repairs or Alterations(Answer when applicable) !j!i t}e 5 Sept;:Septj:G GySt9M GQnSlStinq a11arn�in�j�, 7�� 7'r Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board 9f Health. Signe ® 0 Date ryL?jL/45—<) Application Approved by Date Application Disapproved f r the following reas061 t 1 7 Permit No. Date Issued No. `Fee f THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2pplication for i!5pooar.*p.5tem Construction Permit Application for a Permit to Construct( . )Repair tx )Upgrade( )Abandon(t ) 9-complete System—C Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 165 Madp/P-Pine Rd. ,_�m aquid Nelson Knapp As4.. sessor s aarce Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic service P 0 Box 1089, Centerville Type of Building: Dwelling No.of Bedrooms 4 Lot Size 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 Sand '� 1 Nature of Repairs or Alterations(Answer when applicable) T i i-l e—5 s ent-i s a 3Z_,t•P m consist-i n n of a tank D-box and 3 precast leach chambers with stone all around. S1 ' d U kv< 01 C. Date last inspected: i. Agreement: : , The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system ". ----in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. © ¢��� - Signe �' Date 0/ / ' y Application Approved by l (/�t e .� Date Application Disapproved for the following reaso s 1 Permit No.AdZ2 ..- Date Issued --------------------------- - ----------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Knapp Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( K )Upgraded( ) Abandoned( )by Wm. E. Robinson Septic Service at 165 Mi d—Pine Rd. , Cummaqu d ha constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated ? Installer Wm. F o R oh i n G o n R r_ Designer 'cif."'o Al G ,. The issuance of this permit shah not be construed as a guarantee that the sy teen`^ill function as desgned. l� Date �> �7/90 Inspecto V. • ' � /` 1��� , . THE COMMONWEALTH OF MASSACHUSETTS Knapp PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS lwto pooal 6potem Construction Permit Permission is hereby granted to Construct( )Repair(X )Upgrade( )Abandon( ) System located at 165 Mid—Pine Rd. , Cummaquid 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:Co sfryt f o mu't be completed within three years of the date o is eWt. C �C/ Approved Date: pp by` r w 1/6199 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERNfff(WITHOUT DESIGNED PLANS) T, Williarn E. Rbb ins on,S�fiereby certify that the application for disposal works construction permit signed by me dated , concerning the property located at 165 Mid-Pine Rd. ,Cummaquid meets all ofthe following criteria: • The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. The soil is classified as CLASS I and the percolation rate is less than or equal to:5 minutes per inch. There are no wetlands within lulu feet of the proposed septic system — There arc:no private wells within 150 feet of the proposed septic system' There is no increase in flow and/or change in use proposed There are no variances requested or needed. • The bottom of the proposed leaching facility will no be located less than five feet above the ma dmurn adjusted groundwater table elevation: f Adjust,the groundwater table using the Frimptor method when applicablef If the S.A.S.will be'.located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W.Elevation +the MAX. High G.W. Adjustment DIFFERENCE.BETWEEN A and B _ SIGNED : DATE: _ (Sketch proposed plan of system on back). y:health folder.cen � � ,. �/�d � � t 1 �� ___, _ � L_.6 �, � � � i _— - -- TOWN OF BARNSTABLE LOCATION SEWAGE # OV i VILLAGE A-A- ASSESSOR'S MAP & LOT i i INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 6-C) r LEACHING FACII.TI'Y: (typc) —S--1 <�, rr 4, G (size) . ...NO. OF BEDROOMS, r) I BUILDER OR OWNERx�.+ PERMITDATE: COMPLIANCE DATE: S- C➢-,e, Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom.of Leaching Facility Feet - b .. 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 i .... ...... . •.. Nr ' � V 1 c a _ r ,off p e CO�L110\'t� ALTH OF NLASSACHL SETTS EXECUTIVE OFFICE OF E.N'VIROxmE\TAL AFF.AJRS _ DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE�tZ�TER STREET.BOSTO\MA 0210� (61.j 292-550t, TRUDT COX-- Secre:a-. ARGEO PALL CELLUCCI DAVID B STP. *HS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTMATION Property Address: 1 6 5 Mid-Pine R d. Name of Owner ,,_, sen i,„ P P ummaQu i d Address of owner: Hate of Inspection: ,� 6-C,-J Name of Inspector:(Reese Pdnt)WM a E a Robinson Sr. 1 am a DEP approved s mspector w�aawwaarrt to Section 15.340 of Tide S 1310 CMR 1 S.000) CompanyNarr,e: WM E . Robinson SePT1C .Service MaMng Address: PO Box 1089. Centerville , 1VI q Telephone Number: 7 7- _87-7 E' CERTIFICATION STATEMENT I certify that 1 have personally inspected the sewage disposal system at this address and that the information rep oned 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: l PPaasses Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails �I� Inspector's Signature: � 6 /I�ram..�, Date: _U CJ"� The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty (30)days of completing this inspection. If the system is a shared system or has a design flow of 10.000 gpd or greater.the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection.'The original should be sent to the system owner and copies sent to the buyer, if applicable. and the approving authority. NOTES AND COMMENTS 1® � RAW S EP 8 2000., TOWN s 9dRPJSPAB� �9 t W.v.Ti nor. r , revised Paprierll - C: •-led o-Recrord Panr - , SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM PART A CERTIFICATION Icontirrred) Nop"Address: 165 P4id-Pine Rd. , Cummaquid awry: Knapp Date of Inspection:9 ems—Q INSPECTION SUMMARY: Check B, C, o/ D: A. �SYSTEM PASSES: y 1 have not found any information which indicates that'any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMEKTS: B. S STEM 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. Indicate s,no, or not determined(Y. N, or NO). 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 120)years prior to the date of the inspection: or the septic tank,whether or not metal,is cracked,structurally unsound. shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection If the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipets) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipets)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 pipets). The system will pass inspection if(with approval of the Board of Health): broken pipets)are replaced obstruction is removed revised 5/2/98 Page 2of11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Icontinued) Property Address: 165 Mid-Pine Rd. , Cummaquid Owner: Date of�n C. FU THER 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 the public health, safety and the environment. 1) YSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or,a salt marsh. 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 AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER Pape 3of11 II t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1 65 Mid-Pine Rd. , Cummaquid Owner: Knapp Date of Inspeeti D. SYS FAILS: You must i icate either "Yes" or "No" to each of the following: 1 h ve determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this date mination is identified below. The Board of Health should be contacted to determine what will be necessary to correct.the faiiure. Yes No Backup of sewage into facility or system component due to an overloaded orelogged 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 SY TEM FAILS: You must indics a either "Yes" or "No" to each of the following: The fo owing criteria apply to large systems in addition to the criteria above: The sy tern serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health nd 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 11 of a public water supply well) The owner o operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. rev s e 6 9 Pagi4of11 f . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART B CHECKLIST Property Address: 1 65 Mid-Pine Rd. , Cummaquid owner: � Date of Inspacnb�oh:p 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 mrmat 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 NIA. _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or'industrial'waste flow: v _ The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. _✓ _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: _ Existing information. For example, Plan at B.O.N. _ 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)) v - _ The facility owner (and occupants,if different from owner) were provided with information on the propermaintenanc4j,.4f Subsurface Disposal Systems. re''.ise6 of 2/GE Page 5 of 11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM v PART C SYSTEM INFORMATION ►rop"Address: 1 65- Mid-Pine Rd. , Cummaquid Owner: Date of InspWai-swp FLOW CONDITIONS RESIDENTIAL: Design flow:i (.,0 g.p.d.lbedroom. Number of bedrooms (design): Number of bedrooms lactual):.3 Total DESIGN flow G 4 0 Number of current residents: Garbage grinder lyes or no):�L O Laundry(separate system) (yes or no);dca: If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use (yes or no):,.,d, v 1999 69,000 gal. Water meter readings, if available (last two year's usage (gpd): Sump Pump(yes or no):/L 0 1998 69,000gal. Last date of occupancy:,--6-0 CO MERCIALfINDUSTRIAL: Type of establishment: Desig flow: gpd ( Based on 15.203) Basis f design flow Greas trap present: (yes or no)_ Indust ial Waste Holding Tank present: (yes or no)_ Non•s nitary waste discharged to the Title 5 system: (yes or no)_ Wete meter readings, if available: Last ate of occupancy: OTH : (Describe) Las to of occupancy: GENERAL INFORMATION PUMPING RECORDS and sou c of information: System pumped as part of inspection: (yes or no)46 If yes, volume pumped: gallons Reason for pumping: TYPE OF YSTEM Septic tank idistribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records;if any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known) and source of information: Zn'lit� /Z �j&O S'f Cj 7 Sewage odors detected when arriving at the site: (yes or no)-L6 0 '_el*iseC 5 2 Page 6orII I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'roperty Address: 165 -Mid-Pine Rd. , Cummaquid Owner: Knape Date of Inspection: g-s-a-v BUIL IVG SEWER: (locate on site plan) Depth b (low grade:_ Material of construction: cast iron 40 PVC other(explain) Distan from private water supply well or suction line Diame r Comme ts: (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK: (locate on site plan) Depth below grader r Material of construction: - oncrate_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age_ Is.age confirmed by Certificate of Compliance_ (Yes/No) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffler Scum thickness: 0 ► Distance from top of scum to top of outlet tee or baffle: y Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: A,, G%A-1 comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage. etc.) GREA TRAP: (locate n site plan) Depth be ow grade:_ Material f construction:_concrete_metal_Fiberglass _Polyethylene_othe►(explain) Dimensio s: Scum thi kness: Distance from top of scum to top of outlet tee or baffle: Distant from bottom of scum to bottom of outlet tee or baffle: Date of ast pumping: Comme ts: (recomm ndation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage. etc.) El'�cc`n c�2�5d Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(corninued) ►rop"Address) 65 Mid-Pine Rd. , Cummaquid Owner: Kapp Date of InspftD 9—S—D G� TIG IM OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate n site plan) Depth b low grade:_ Material f construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensio s: Capacity: gallons Design flo gallons day Alarm pre ent Alarm lev I: Alarm in working order: Yes_ No_ Date of revious pumping: Comme s: Iconditi n of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_V (locate on site plan) n' Depth of liquid level above outlet,invert: Comments: Inote if level and distribution is equal. evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER:_ (locate on site plan) Pump in working order: (Yes or Not Alar s in working order(Yes or No) Comm nts: (note c ndition of pump chamber, condition of pumps and appurtenances,etc.) revisela 9/2/9C - Page 8ofII y i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(caftnued) 'roperty Address: 1 65- Mid-Pine Rd. , Cummaquid owner: KK Date of Irupec'd&#PP SOIL ABSORPTION SYSTEM(SAS): (locate on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number:_ 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 h dr lic failure jevel of ponding, damp soil, co dition of v getation, et 1 CESSPO _ (locate on si plan) Number and c nfiguration: Depth-top of li uid to inlet invert: Depth of solids aver: )epth of scum yer: Dimensions of sspool: Materials of co truction. Indication of gr undwater: inflev. (cesspool must-be-pumped as part of inspection) Comments: (note condit n of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc) PRIVY:_ (locate on si a plan) Materials of onstruction: Depth of soli s. Dimensions: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) F _ d- c- _ _ _ L Pagc 9 of I I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Icontinued) 'roperty Address: 165 Mid-Pine Rd. , Cummaquid owner: Knapp Date of Inspection: S- 9— SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) bl 1 I � q i L 0 �N d p c-o-,517`7 1 rev sec S;'2/9E Payc10ofII • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM MIFORMATION(eoednued) ►op"Address:1 65 Mid-Pine Rd. , Cummaquid Owner: PP Rna Date of Inspection: �S NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Deep Groundwater depth: Shallow Moderate SITE EXAM Slope Surface water Check Cellar Shallow wells l Estimated Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: . /Obtained from Design Plans on record f V Observed Site(Abutting property, observation hole. basement sump etc.) Determined from local conditions v/Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators. installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) rev se:. 9/2/9E Page 11of11 po TROY WILLIAMS t SEPTIC INSPECTIONS T a j 0 Certified by MA Department of Environmental Protection �1 _ * � (508) 385-1300 19 Hummel Drive South Dennis, MA 02660 i � _1 P% C OFY m,w COMMONWEALTH OF MASSACHUSEgTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONmENTAL`.PROTECnON ONE WINTER STREET, BOSTON MA 02108 (617)292-5500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM' PART A CERTIFICATION Property Address 6 S M:,1 Name of Owner_ q►'^N y J•`� Address of Owner• / lS • of 2 76 Date of lnspection: // /�c) Ci u ah sh cam'd a Name of Inspector:(Please Print) Troy Wifflams 1 am a DEP approved system inspector pursuant to Section 15.340 of Trde 5(31 O CMR 15.000) Company Name: Troy Williams So tin c Insnactions MaWM Address: 19 Hummel Drive So. Dennis MA 02660 Telephone Number: (508) 385-1300 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: -Z Passes Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspectors Signature: S Ad p Date: 619 /U The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to tfte system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS Although system meets the minimum requirements set forth by the Massachusetts Department of Environmental Protection,certification is not to be construed as a guarantee of future working condition of system,piping or components. This inspection represents the conditions of the system on the Date of. Inspection noted above. 6 �10OO revi SPri q /-) /9p SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 165 Mid Pine Drive, Cummaquid,MA Owner: Nelson Knapp Date of Inspection: June 9, 2000 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: 1 have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system,upon" completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes,no,or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s).' The system will pass Inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed revised 9/2/95 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) 165 Mid Pine Drive, Cummaquid,NM Property Address: Nelson Knapp Owner: June 9, 2000 Date of Inspection: C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: A11111 Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: T Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT.THE SYSTEM IS FUNCTIONING W A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) 165 Mid Pine Drive,Cummaquid,MA Nelson Knapp Property Address: June 9, 2000 Owner: Date of Inspection: D. SYSTEM FAILS: N 14 You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. _ Liquid depth in cesspool is less than 6" below invert or available volume is less than 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: N��q You must indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area=IWPA)or,a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. -revised 9/2/98 Page 4ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST 165 Mid Pine Drive,Cummaquid,MA Property Address: Nelson Knapp Owner: Dace of Inspection: June 9, 2000 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes,, No t// _ Pumping information was provided by the owner,occupant,or Board of Health. }[ _ None of the system components have been pumped•forat 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 NIA. ✓ _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. v _ The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes ww uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: _ Existing information. For example, Plan at B.O.H. Determined in the field(if any of the failure criteria related to Part C is at issue,approximation.of distance is unacceptable) 115.302(3)(b)I The facility owner(and occupants,if different from owner) were provided with information on the proper inaintenance of Subsurface Disposal Systems. revised 9/2/98 Page 5ofII i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 165 Mid Pine Drive,Cummaquid,MA Owe' Nelson Knapp Date of Inspection: June 9,2000 FLOW CONDITIONS RESIDENTIAL: Design flow: //o g•p.d.lbedroom. Number of bedrooms(design): 3 Number of bedrooms(actual):_ Total DESIGN flow ,330 Number of current residents: �Z Garbage grinder(yes or no):--yo-s Laundry(separate system) (yes or no):_&/O; If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use(yes or no): IV# Water meter readings,if available(last two year's usage(gpd): g9/� = /'&doOyg //oa f Sump Pump(yes or no):� Last date of occupancy: COMMERCIAL/INDUSTRIAL: A11,4 Type of establishment: Design flow: qpd ( Based on 15.203) Basis of design flow Grease trap present:(yes or no)_ Industrial Waste Holding Tank present:(yes or no) Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings,if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and sourfce of information: Syst6m pumped as part of ins ection: (yes or no),�,16 If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM _ Septic tank/41"Qt"e., efNsoil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known) and source of information: I97 3 Sewage odors detected when arriving at the site:(yes or no) ^lU f revised 9/2/98 Page 6ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Proms Address: 165 Mid Pine Drive, Cummaquid,MA Owner: Nelson Knapp Date of Inspection: Nelson 9, 2000 BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction:-k Cast iron—40 PVC her(explain) ro..r � ✓r Distance from pnvaEa water su6ply well or suction line Diameter '1 r Comments:(condition of joints, venting, evidence of leakage,etc.) Gor- r. SEPTIC TANK dL �s H� a �v 6/�r+rs wt rywy o►—r.,a,� �m� b� a � �o-1C'A- (locate on site plan) Depth below grade:� ( ! ✓ '5 c✓ � Material of construction:2oncrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age_ Is.age confirmed by Certificate of Compliance_(Yes/No) Dimensions: 'X IF XG Sludge depth: all Distance from top of sludge to bottom of outlet tee or baffler Scum thickness: UN Distance from top of scum to top of outlet tee or baffle: /klo J .*+ Distance from bottom of scum to bottom of outlet tee or baffle: ,V-/°J 41) , How dimensions were determined: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structuraHntegrity, e 'dance of leakage,etc.)�•.�,. �c� 7�a.-�✓ / ,.0 ..�o.-c- o✓ cQ�� !�u4. w .� o r Lt . :. r .c,� ( a c. J/ G.r cc-e.r. f 14 4- cr � �r � uc q }-cod. ✓�n� s✓ Scrccay ✓Oor. GREASE TRAP: w �ti X r✓ r..:trot. (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass Polyethylene_other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 165 Mid Pine Drive, Cummaquid,MA Owrw: Nelson Knapp Date of Inspection: June 9, 2000 TIGHT OR HOLDING TANK:(Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensions: ---- - - _ Capacity gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order:Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX:-411/9 (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is a ual,evidence of solids carryover, evidence of leakage into or out of box, etc.) �huc fGc� lq PUMP CHAMBER:--V//, (locate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) revised 9/2/98 Page 8ofII f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 165 Mid Pine Drive,Cummaquid,MA Owner: Nelson Knapp Date of Inspection: June 9,2000 SOIL ABSORPTION SYSTEM(SAS):- (locate on site plan,if possible; excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number: 6 ��G t! cu�' )' f tr 1 1, z ` S-/dy, 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 o hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) - Lt�c,l.- t7,f Way �.. .1 �.! i� t/ U�o� G.rA�"er .r�r^�s C.n 4- r r c ci I C_I —, " l oo a.4- 4 i/ G [f� .7 c N +ti S r� a r✓� s N c l a7 c�/S ✓'`� wJ l:c. ),art cw, s th CESSPOOLS: �y o'� /hS , 3 no q✓uro-.r.f (locate on site plan) r✓_vt� i�-iov. T �c�: c •+.S / P,�L s or j3e-5 Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revised 9/2/98 Page 9ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property address.Owner: 165 Mid Pine Drive, Cummaquid,MA Date of Inspection: Nelson Knapp June 9, 2000 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 30-Ik-' 37 I 25 ` /aop��Lay 38 ' f revised `9/2/98 Page 10of II o SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(corWwmed) Property Address: 165 Mid Pine Drive,Cummaquid,MA Owner: Nelson Knapp Date of Inspection: June 9, 2000 NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep 1/ SITE EXAM Slope✓ Surface water Check Cellar Shallow wells Estimated Depth to Groundwater. Ir Feet Please indicate all the methods used to determine High Groundwater Elevation: ` Obtained from Design Plans on record Observed Site iAbutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records _Checked local excavators,installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed)) 6 C_a 'I' GA D N ✓► I I t.�L')G✓L- ,� �'I�H V_ A(J a_(I'G� �� �t �;.✓J �j✓e-.�..� A f' �. G�c.✓�-h ov't p v� Na r j�, hO�. ►•� d�'Dper 'y �� � I/�J 4JA.yt.✓ ✓hJ. 0. � � l'ti • h vF✓w. �' revised 9/2/98 Page 11 of 11 ti w A 1y TROY WILLIAMS SEPTIC INSPECTIONS Certified by MA Department of Environmental Protection (508) 38571300 19 Hummel Drive South Dennis, MA 02660 COMMONWEALTH OF MASSACHUSETTS 10 EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS4_� ,.,- 08 DEPARTMENT OF ENVIRONMENTAL PROTECTIr0NTTt c� ONE WINTER STREET; BOSTON, MA 02108 617-292.55003�I� TR64E r, WILLIAM F.WELD �TRUDY C�OJiE Govcmor SccrctArV ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioncr PART A l CERTIFICATION Property Address: 165 M8"�/�'"e RCS C• .""r++a,,-;�ddress of Owner: (�t�, /V't I s v:•t Date of Inspection: ' ( (If different Name of Inspector: Troy Williams P.6 - &'K ;?76 I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 1S.000) 1 C' /'a«w�ci qV, c� /t Company Name: Troy W1 11df05 Septic InsDectiOCls - / ♦ ' Mailing Address: 19 Hummel Drive , Snuth Dennis , MA 02660 OaG37 Telephone Number: _1r508T385-1300 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection: The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes Needs Further Evaluation By the local Approving Authority _ Fair q 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: AI SYSTEM PASSES: ---ZI have not found any.information which •indicates that the system violates any of the failure aiteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: BJ SYSTEM CONDITIONALLY PASSES: A///Jl On or more system components as described in the 'Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined(Y, N,or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank. failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (—i—d 04/25/17) Paq• l.or 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 165 Midpine Road, Cummaquid, MA Property Address: W. Nelson Knapp Owner: August 3, 1998 Dale of Inspection: 61 SYSTEM CONDITIONALLY PASSES (continued) /U//9 Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed I 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 pipe(s) are replaced obstruction is removed C1 FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: /V//-g Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 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, llr APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet 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 1 of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER I I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 165 Midpine Road, Cummaquid, MA Owner: W. Nelson Knapp Date of Inspection: August 3, 1998 Dl SYSTEM FAILS: N1/9 You must indicate ewer "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. 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. El LARGE SYSTEM FAILS: /VIII You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200•feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area-IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (—I..d 04/25/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART B CHECKLIST 165 Midpine Road,Cummaquid, MA Property Address: W.Nelson Knapp Owner: August 3, 1998 Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Y No 7 _ 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. /VLi�f 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. _ All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material-of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: The facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of / Sub-Surface Disposal System. i9 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)) (r.vi..d 04/25/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 165 Midpine Road, Cummaquid, MA Owner: W.Nelson Knapp Date of Inspection: August 3, 1998 RESIDENTIAL: FLOW CONDITIONS Design flow:1-1y___g.p,d./bedroom for S.A.S. Number of bedrooms: Number of current residents:02 Garbage grinder (yes or no): Y95 Laundry connected to system (yes or no): TES Seasonal use (yes or no):NO Water meter readings, if available (last two (2) year usage (gpd): 97 oyp Sump Pump (yes or no):�� Last date of occupancy: C- v ;t J. COMMERCIAUINDUSTRIAL• lv1119 Type of establishment: Design flow:_gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information- "; / / /J4, TD thS On f7C✓ th j !An L�tOc+n� ZStdt^�✓ System pumped as part of inspection: (yes or no)_O ' If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM Septic tank/di9tri6k'1iera4*Wsoil 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: yV ; _ ; ,,, �, 4. l 16y" 14- "14l°rou. I y73. Sewage odors detected when arriving at the site: (yes or no) No SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM INFORMATION (continued) Property Address: 165 Midpine Road,Curnmaquid, MA Owner: W.Nelson Knapp Date of Inspection: August 3, 1998 BUILDING SEWER: IV14 (locate on site plan) Depth below grade: Material of construction: _ cast iron _ 40 PVC _other (explain) Distance from private water supply well or suction line Diameter j Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:2 (locate on site plan) Depth below grade: Material of construction: -Z/Concrete _metal _Fiberglass _Polyethylene —other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions:_ S 1 A- 9 �x l oa 6 Sludge depth: /� Distance from top of sludge to bottom of outlet tee or baffle: 3 Scum thickness: A/oAt Distance from top of scum to top of outlet tee or baffle: NO Distance from bottom of scum to bottom of outlet tee or baffle:ALL Sc,-"q How dimensions were determined: /Or. 6 _ Comments: (recommendation for pumping, condition of inlet and outlet tees or affles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (210-, c_r•a. c �� dv � -f as dr l� `n o - ✓` N '�Ti-L h v' v� G r C�.G v. T t GREASE TRAP: Jr (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (rrvi sed 04/25/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: m 165 Midpine Road, Cumaquid, MA Owner: W. Nelson Knapp Date of Inspection:August 3, 1998 TIGHT OR HOLDING TANK:N/(Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensions: Capacity: gallons . Design flow: gallons/day Alarm level: Alarm in working order_Yes; _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: NIA (locate on site plan) Depth of liquid level above outlet invert: Comments: (note iflevel and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) Sill 4, k<cl h tom/IlL Ho cf- C�ok Tb`�N .� Yf✓ ( ,j. PUMP CHAMBER: (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 165 Midpine Road, Cummaquid, MA Owner: W. Nelson Knapp Date of Inspection:August 3, 1998 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: i leaching its, number: dui 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, condition of vegetation, etc.) I _ C' 6010'e- Will, w J.-,CA 740- ci W ✓ INS`otC.fj641 . CESSPOOLS: _ �V/11 (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: IN// (locate on site plan) Materials of construction: Depth of solids: Dimensions: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) 04/25/97t v.4. a or 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 165 Midpine Road, Cununacp id, MA Owner: W. Nelson Knapp Date of Inspection: August 3, 1998 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) Port,L9 f ►vopYy�fo ti got 1.. (ravlaad 04/15/97) Page 9 or 10 SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 165 Midpine Road,Cummaquid, MA Owner: W. Nelson Knapp Date of Inspection: August 3, 1998 Depth to Groundwater_ Feet adjustod high groundwater lcvcl Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record VObservation 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) v i s U cc, / ci(••ono IH Nr / � yYoJ�.uQ KJ.:i �cr 'ec�2.� (r—i..d 04/2s/97) �.- ., v.oe 10 or 10 �•. . No. L 7--------- Fxs... ,r:................._ THE COMMONWEALTH OF MASSACHUSETTS 01, L BOARD OF HEALTH ............... ......................... OF................................................................................................... Applira#ion for Uiipv,i al 19orkii Tonstrurtioaa Vanfit / Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal ��Syste tm a f� �/j s l .............. .............................................. io r_/�A� / � orLot No. . �.. � :.:l.._. ............ ...�� �. �............... ..... ...... :..... ........... (6c �w- ............. Ownc !/ .. .., .. .........A.dress C'......••• ..Installer............................ .. ... ` Address Q Type of Building Size Lot... ? ! ...........Sq. feet U Dwelling—No. of Bedroom�s�...�..".... ' .Expansion Attic ( ) Garbage Grinder (cam a Other—Type of Building'!�wt.......... No. of persons......i r,:,P............... Showers. ( ) — Cafeteria ( ) a' Other fixtures -•-•..............•...._...........- .. . W Design Flow........... ................... •-gallons per person per day. Total dail flow............................................gallons. Septic Tank—Liquid capacit _.gallons Length-- Width... .......... Diameter___ ..... Depth................ x Disposal Trench—No._.____ ...-•. Width....................Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.li�� __..__ Diameter------------_------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution bo ( ) Dosing tank ( • ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (i, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ----------------- O Description of Soil-------------------- -•------------.-- x W •-------------------------------------------------------------------- ----•------------••-------•---------------------------•--------------------------•--------------------------------........._...... V Nature of Repairs or Alterations—Answer when applicable................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— e undersigned further agrees not to place the system in operation until a Certificate of Compliance h e iss b e board of health. Signed... .. ... .. ...... ... ......................•-•--•••---•.......•--..... /•y Date Application Approved By- --- ......... . • ••--•- --------------•------------ •--••--•------ - ------------ Date Application Disapproved for the following reasons:................................................................................................................ ................---•-•---.............---•--•-----------.....--------------------••-••--••-•.......................................................................................................... Date PermitNo......................................................... Issued............•........................................... Date THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) IA �� l'-, m / �(, � LI DATA ! y ...... F$$..fi....................._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........ ......................OF................................----• -_.. Applirativit for Biagi osal Works Tonstruction "unfit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at, <..✓f!��,1 .��af..__, .................. ------•-- ---------••-•-•••---------_-••••---.. t � / Q do dre 1 ) /Y or Lot No. f ow x a "5� E 8 ,: F A dress\ W �a✓.':'� ...d,..:L� .�ij.A3�eti�t�3i�1�.a �.�.... /...........(..�.a.��'w._--.�+C� 1C��:2M1',:Sl� .e!S.—:Y:1.......... ... ....• Installer /!! Address Type of Building Size !� Sq. feet Dwelling—No. of Bedrooms......... ............................Expansion Attic ( ) Garbage Grinder aOther—Type of Building ;- ........... No. of persons____.:�!_______________ Showers ( ) — Cafeteria ( ) P4Other fixtures .._____-_---• ••.....•--•-••---•••••••••••••••-...._......_-•-••-----•••--......._--••-•••••----••--••-: r W Design Flow...........;z.. .......................gallons per person per day,�idt Total dais floDiame e. '" `__.._._ Depth.--gallons. W Septic Tank—Liquid capacit gallons Length.._ . x Disposal Trench—No....... ........... Width.................... Total Length.................... Total leaching area....................sq. ft. 5 Seepage Pit No.?.. %` Diameter____________________ Depth below inlet.................... Total leaching area.................. ft. Z Other Distribution,boi/( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................ndilutes per inch Depth of Test Pit.................... Depth to ground water........................ fs, Test Pit No. 2________________minutes per inch Depth of Test Pit.................... Depth to ground water................... a --•-_____- ---------------- 'i. '> ,r :"` O Description of Soil = .. a'''f-••••--..: -- -.:. `�1-•------------------------------------------------------------ U .•-••-••••_.___•-••••-••-••-••--•----•-•--••----••••••••••................•••-••-•-•----••--•••---•------------•••••••--••-•_-_...._.---•-•------•------•--___••-•••••--••--•••-•••••-____-___•••••••••-- W UNature of Repairs or Alterations—Answer when applicable.._............................................................................................. •••------•-----------•-------------------•-•----••-•-•--•---------------•----------•--•••••..........._..----•---------.....------...--------•__....--------••••----- .................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article YI of the State Sanitary Code— ze undersigned further agrees not to place the system in operation until a Certificate of Compliance his Ueen issv b)K e board of health. ry Signed.. _________________________________ r .__._.._... J _ S w. s Date Application Approved By... •-_ i__s,;y .__.......... ...... ! __ ' �--d�°- �•----•-- ---_-•-----• ........ --------------- Date Application Disapproved for the following reasons:...................................._........................................................................... --••-•--•.................................•---------•-----.•..••---------••••-•-----..._____•-•-............_..__...•-----••••-•••-••-•-•••-•-•-•-••----•----........................................... Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD ,OF HEALT O H .. l I 111& ...-4..t;.a.a++9 i y c,,�she F ...............................O F..........n>.z.:.............. ................... ..:.............................. Qlatifirate of Tompliaure THI,y.(IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) x at-1 jC i4. " R ! F ? # s f ! �.._._... ...._.t__ ._a._._._¢.b..t_.O� .J/ :r_r_._. �e.._.§!e ......._iA-.v�y e�RIF._. _.S4a• t°/ _ .`' �.._. ._........4..d ______________ has been installed in accordance with the provisions of Article XI of Tliq State Sanitary Code as described in the application for Disposal Works Construction Permit No----------------------------------------- dated_:._-_---_-_.-__-___.__.--_____.._._......_ _ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...............................••-••-•••--•-•-....._..._-_..._.______-___....... Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ... ... OF........ ...... ... ....._--- ...--`.-----...._...._.......__............. No... t........ FEE." ..... ..:.:. Permission is hereby granted E ._.....--•-••..................... ... .................................................................................. ...... to Construct ( ) or Repair ( an Individual Sewage Disposal System o 4 :,,.1.......... ..c............... ......................... ..-•- _...._. .f. __............._...._........._........___._...._.............. Street as shown on the application for Disposal Works Construction Permit-Nb.._ -_.:............ Dated_...... :f�, Z `<:!' Board of Iicalth DATE ✓ �` i jf FORM 1255 Pi0895 & WARREN, INC.. PUBLISHERS // D+• ���,/•.. .