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0275 MIDPINE RD - Health
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Large volumes of water have not been introduced into the system recently or as part of this inspection. 1/ As built plans have been obtained and examined. Note if they are not , / available with N/A. V The facility or dwelling was inspected for signs of sewage back-up. The site was inspected for signs of breakout. . All system components, excluding the SAS, 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 SAS on the site has been determined based /on existing information or approximated by non-intrusive methods. V The facility .owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential number of bedrooms number of current residents ' garbage grinder, yes or no >> laundry connected to system, yes or no seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if available: -I1• Last date of occupancy GENERAL INFORMATION Pumping records and Source of information: System pumped as part of inspection, yes or no if yes., volume pumped Reason for pumping: Typtt11/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) Other (explain) Approximate age of all components. Date installed, if known. Source of information: rzs )ek!�yoprrZ." L�4 ) C) /6-,/Sewage odors detected when arriving at the site, yes or no 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK: (locate on site plan) depth below grade:_ material of construction: /' concrete metal FRP other(explain) dimensions: (> GU U ` �- S, > r & sludge depth 4;7- distance from top of sludge to bottom of outlet tee or baffle -9 ' ' scum thickness distance from top of scum to top of outlet tee or baffle distance from bottom of scum to bottom of outlet tee or baffle Comments: (recommendation for pumping, .condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of 1 akage, recommendations for repairs, etc. ) DISTRIBUTION BOX: (locate on site plan) depth of liquid level above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc. ) PUMP CHAMBER: (locate on sit plan) pumps in working order, yes or no Comments: (note condition of pump chamber, co dition of pumps and appurtenances, recommendations for maintenance 0 repairs,etc. ) 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM 7NFRMATION continued 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; ! r. dfrx ii A.c. Type leaching pits and number leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) C) CESSPOOLS (locate on site plan) : number and configuration depth-top of liquid to inlet invert depth of solids layer depth of scum layer dimensions of cesspool materials of construction indication of groundwater inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,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, recommendatiq s for maintenance or repairs,etc. ) 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' � I 10 DEPTH TO GROUNDWATER 0= 6 depth to groundwater method of determination or approximation: 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined", explain why not) Backup of sewage into facility? Discharge or ponding of effluent to the surface of the ground or surface waters? Static liquid level in the distribution box above outlet invert? Liquid depth in cesspool <6" below invert or available volume< 1/2 day flow? Required pumping 4 times or more in the last year? number of times pumped Septic tank is metal? cracked? structural) unsound? substantial p Y infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy: , below the high groundwater elevation? 4Lwithin 50 feet of a surface water? IV within 100 feet of a surface water supply or tributary to a surface water supply? within a Zone I of a public well? Awithin 50 feet of a bordering vegetated wetland. or salt marsh (cesspools and privies only, not the SAS) ? within 50 feet of a private water supply well? /v 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 analysi for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. TOWN OFF Q ti 5 l��I BOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D - CERTIFICATION N -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS Jr I/Y1►y T /lam c= r� 4 (i ASSESSORS MAP, BLOCK AND .PARCEL # OWNER' s NAME PART D - CERTIFICATION NAME OF INSPECTOR W.E. Robinson Sr COMPANY NAME W.E. Robinnon Septic Service COMPANY ADDRESS P.O. Box 1089 Centerville MA 02632 Street Town or City State ZIP COMPANY TELEPHONE ( 508 ) 775-8776 FAX CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate, and complete as of the time of inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on site sewage disposal systems. Check ne V System PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any ,failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection which I have conducted has found that the system fails to protect the public health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form. Inspector Signature v Date One copy of this certification must be provided to the OWNER, the BUYER (where applicable ) and the BOARD OF HEALTH. * If the inspection FAILED, the owner or operator shall upgrade the system within one year of the date of the inspection, unless allowed or required otherwise as provided in 310 CMR 15 . 305 . partd.doc - TOWN OF STABLE LOCATION• Y27jQ' SEWAGE.#_ ASSESS 'S MAP&LOT 02 a ASLPdcrV-A>.T 33=1 WHIPS NAME&PHONE NO. 'n SEPTIC TANK CAPACITY CY LEACHING FACILITY: (type) / (size) ��LEACHING i NO.OF BEDROOMS BUILDER PERMITDATE: COMPLIANCE DATE: i Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 3 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 A+ Feet within 300 feet of leachin facil' ) .z�c • �I,�/rs , Furnished r4pld , �r Or C (,o i i } F 1. 3qg — 0,4-a g 30 .00 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Ap.plirFation for Uiopo!3 al Wor1w Toaa.itrurtion ramit " Application is hereby made for a Permit to Construct ( ) or Repair (x ) an Individual Sewage Disposal System at: ....2 7 5 Mid Pine Rd Cummaqu i d----•-•• -----------------------•-------••-•--------- Location-_address or Lot No. V.H. Downs ......................_.......................................................................... -----------•-------•---•---------•--•••---••--•--••-••--------•-------.........--•--.....-----•... owner Address a VI.E. Robisnon Septic Service P.O. Box 1089 Centerville Installer Address UType of Building 3 Size Lot............................Sq. feet Dwelling— No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( n� Other—Type of Building ............................ No. of persons--_----.------..-..------. Showers ( ) — Cafeteria ( } Q' Other fixtures •-----_-----------------• -------------------------------------------- W Design Flow............................................gallons per person per day. Total daily flow-..-----------------------------------------gallons. WSeptic Tank—Liquid capacity............gallons Length--- ------------ Width.-..------------ Diameter---.------------- Depth---------------- x Disposal Trench—No. .................... Width-------------------- Total Length.................--- Total leaching area....................sq. ft. Seepage Pit No--------_---------- Diameter-------------------- Depth below inlet..--................ Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by-------- -------------••------••-...-•••-••--•••......--•-•-....---•------ Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.....-------------. Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit............--...... Depth to ground water........................ -•-------------------•--------------------------........-•-•------•--------•••-•----•••......_---•--......................................................... Descriptionof Soil.........sand.................................................................................................................................................... x w ---------------- ------------------•---------------------------------------•-----•-----------------------------------------------------------------------------•-------...........••-••-......-•---••-- U Nature of Repairs or Alterations—Answer when applicable........ nstal-l-- a___Title.... . leaChtrench._._.. ..--••-••-•••••-------------•-•--••-•--•••••--------...----•••••••••-----------------••---••----••--•••••---•-•----------------....----•-•------------••-•-----•-••••...•....•--•---••-••---•--------•-- Agreement•. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee iss d hy--rhe boa of health. r Signed .-- f ?'' .._....,. ............ ...... ..........................:...... li ti n Approved B , ��� . / —�� - ......................._......... - .........App ca o pp y �/ Date Application Disapproved for the following reasons: ........................................................................................ .............. .. ..... ..... ............ ......_.... ... ....... ._............_.....--- .. ....._..............._._.............. ........................................ Permit No. ----- -- -��.. �&-.. ------------ Issued ------------ '..~ �-� f...... .......... Date fl THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Tics- ifirate of Tantyliance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (X ) by ....W.E. Robi snon Septic._Service-------------------------------------------- --------------------- InsnJler at ....275 Mid Pine Rd C .... m - .... ..... - ..... - has been installed in accordance with the provislons of TITI_E��he St teEnvirondmacnttal Code asd described in the application for Disposal Works Construction Permit No. 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 j-_ A, TOWN OF BARNSTABLE 30 .00 NO..... - FEE ----. ....... Rojimial Workii Tnni#r ian "Vrrnnit Permission is hereby granted.-.....1T-o-E......Ro-b!risoa--.Se t-ic...SGrvi-ce------------------------------------------------------- to Construct ( ) or Repair ( x) an Individual Sewage Disposal System at No....... 75.-Mid.- IuP-and----Cumroaquid--••------------- •----------....-----•-- Street as shown on the application for Disposal Works Construction Permit No.,?3--�6_G..-?Dated----.P--..16-.--.. 'Board of Health DATE--.................k.. -...1-4........X5........................ FORM 36508 HOBBS Q WARREN,INC..PUBLISHERS r 3 (49 -- C)aD - 74 No.................. ...0..................... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Allp iration for Diti-pnittl lVorkii Tontitrurtion Vantit Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal System at: 275 -Mid Pine Rd Cummaauid .........--•........................................•------•---------••---•--•-••-•------•-------. ---•---•----•-----•---------•------••----------•--•--•-•••-...._.._......-------•---••-------••--- V.H. Downs Location-Address or Lot No. Owner Address a I.E. Robisnon.Sept�g. Service P.O. Box 1089 Centerville Installer Address UType of Building 3 Size Lot.......................... Sq. feet ,., Dwelling— No. of Bedrooms._.........................................Expansion Attic ( ) Garbage Grinder ( njo Other—Type of Building _-------------------------. No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Other fixtures ------------------------------- - - W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. , W Septic Tank—Liquid capacity------.---.gallons Length---------------- Width---------------- Diameter._........... Depth---------------- x Disposal Trench— No. .................... Width.................... Total Length-------------------- Total leaching area....................sq. ft. Seepage Pit No..................... Diameter....--..--.-.-.----- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by_---------------- ......`............................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water.......... ......... G14 Test Pit No. 2................minutes per inch Depth of Test Pit.......... _-. Depth to ground water........................ -----------------------------------------------------------------------•----.. ....................................................................... Descriptionof Soil sand--•-----------------------------------------------------------------=----------------------------------------------------------••-•---------------- •x W . -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- '! U Nature of Repairs or Alterations—Answer when applicable.. .a Title V-_-leachtrench-----. Y a_ ----------------------------•------------------------------------:.....-------------•••-•--- ...... ---------------------------------------------------------------------------------........----••-- } Agreement: f l/ f, '�7 The undersigned agrees to install theiforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the Statel /ironmental Code-Tlie undersigned further agrees not to place the system in operation until a Certifi e�f<Compl4 nce has been iss d tzy_the boa of health. r Signed;,:: {// -- ---- - ------------- ,...:.--................. ��..... ---------- ...�.-�/ Dare A licauon.A roved B ... �r . - Ap. -/v —�� PP ; PP Y - ...._.._.�ce- -------------- Application Disapproved for the following reasons: ........... � : r-.... .. ..... . f. �-------- . ... . ..................__.... ... .. ......_..................... Permit No. ...... .................. .......... 1 ?i.-..... r <`� Issued -------------P"_^ /() S',S 1 Dace 1 j��._.....� _—— —a—, r._,_,_-_._- —————— ----•------------ - 4^ ij CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL NVOItKS CONSTItUC'TION PERMIT (WITHOUT DESIGNED PLANS) I, All , hereby certify that the application for disposal works construction permit signed by me dated 16'— � , concerning the property located at '? �� a " �'c' 4� meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. SIGNED: DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER (Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submiltedl.. .� �' . +. � �� �� �� � � �, t Gd � � L a COMMONWFALTH OF MASSACHUSETTS EXECUTm OFFICE OF ENVIRONMENTAL AFFAIRS _ DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM F6RM PART A CERTIFICATION Property Address: 275 Midpine>Road ummaqui Owner's Name: Russell LaPorte Owner's Address: 275 Midpine Road.- ��, —ar Date of Inspection: (0 Cietn —r Name of Inspector.(please print) ,S-an Jonesi �y Company Name: William E. Robinson Septic Service Mailing Address-. P O Box 1089 Centerville, MA -' TelephoneNumbirc (5081 775-8776- r r. CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the inform ion reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper functio and maintena of on site sewage disposal systems_1 am a DEP approved system inspector pursuant to S lion nce 15340 o[Title 5(310 CNIR 15.000)- The system: Condtttonafly Passes '. Needs Further Evaluation by the Local Approving Authority Inspector's Signature: Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heatth,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. e� bE N soft.,i s o..trr a l l o�. Y a-1 +..ice Ais SePi,c s`yskw Notes and Comments C)d5151V 1 c�VE. SAOAd 6•e 00n 04J (1,e rid a -v�a,1. vSCCv/l l�'Ct Oc SySk.ts. , ."This report only describes conditions at the time of inspection and under tho conditions of use at that `time.This inspection does not address how the system will perform in the future under the same or different C J . d'fconditions of-use. Title 5 Inspection Fomr 6/15/2000 page I S Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued). Property Address: 275 Midpine Road Cummaquid Owner. Russell LaPorte _ Date of Inspection: a Inspection Summary: Check A,B,C,D or E/ALWAYS complete 90 of Section D A. Sys m Passes: . .. I have not found any information which indicates that any of the failure crstetia described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evalimted are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health.will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.if"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exrduation or tank failure is imminent System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. •A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. _ ND explain: Observation of sewage backup or break out or high static water,level in the distribution box due wbroken or obstructed pipe(s)or due to a broken,sealed or uneven distribution box.System will pass inspection if(with approval of Board of Health): t broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: -!be system required pumping more than 4 times a year due tobrokcn or obsutuxed pipc(s).The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is mmmrod ND explain: Page 3 of 1 i OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:- 275 Midpine Road Cummaguid Owner. Russell LaPorte Date of Inspection: i C. Further Evaluation is Required by the Board of Health: ! VIA Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. I 1. System will pass unless Board of Health determines in accordance with 310 C141145'.303{lib)that the system is not functioning in a manner which will protect public health,safety-and the*environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the-public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. , — The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. The system has a septic tank and SASand the SAS is within 50 feet of a private water supply,well. _ The system has aseptic tank and SAS and the SAS is less than 100 feet but 50 feet or more front a , private water supply well°• Method used to determine distance ••This system passes if the well water analysis,performed at a D£P certified laboratory,for coliform bacteria and volatile organic compounds-indicates that the well is.free,from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5'pprn,provided that no other , failure criteria are triggered.A copy of the analysis must be attached to this form_ 3. Other: ' t , 3 Page 4 of 1 t OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SENVAGE DISPOSAL SYSTEM_INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 275 Midpine Road ummaqui Russell LaPorte Owner. Date of Inspection: J -7 DI System Failure Criteria applicable to all systems: You must indicate"ycs"or"no"to each of the following for all inspections: Yes No/ _ ►/ n ckup 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 Jcesspool _ 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 J of times pumped _ _ Any portion of the SAS.cesspool or privy is below high ground water elevation. --�L/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 f et from a private Aawr supply well with no acceptable water quality analysis.[This system passes if the well water analysis, performed at a DEP certified laboratory,for eoliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen.is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.l (YestNo)The system faits.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 faihirc. r E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd- 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) 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-1WPA)or a mapped Zone I of a public water supply well If you have answered"yes"to any question in Section E the system is ca n—idered a significant threat,or answered "yes"in Section D above the large system has faiW-The t wncr or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system o,.%rer should contact the appropriate rcgional office of the Department. 4 Page 5 of 11 OFFICIAL-INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address.• 275- Midpine Road ummaqui Owner: Russell LaPorte Date of Inspection: (o,W_9a 2� v F , Check if the following have been done.You must indicate`5res"or"no"as to each of the'following: Yes -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 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 f? ✓ — Was the siti inspected for signs of break out? Were all system components,excluding the SAS,located on site? _ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and`depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)`ou the site haslbeen determined based on: Yes 'o Existing information.For example,a plan at the Board of Health.' Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CtAR 15.302(3)(b)) ' s s •I. .a S Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 275 Midpine Road Cummaquid Owner: Russell LaPorte Date of Inspection: FLbWCONDITIONS RESIDENTIAL Number of bedrooms(design).-_''j Number of bedrooms(actual). M No b 40 DESIGN flow based on 310 CMR 15203(for example: 110 gpd x g of bedrooms): Number of current residents: Sec Alo ft.$ +401e Does residence have a garbage grinder(yes or no):_e5 Is laundry on a separate sewage system(yes or no):OW [if yes separate inspection required] Laundry system inspected(yes or no): -v Seasonal use:(yes or no):1L 2 0 0 5-2 0 0 6 88, 000 Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or nor_CS - 73,000 ` Last date of occupancy. GuNtN COMMERCIAIANDUSTRIALf�- Type of establishment: / Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Tide 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: fur Peco'rls - e-`�zf`f 7-3 r�s• Wass system pumped as part of the inspection(yes or no):�s Ys P um P � Srze o�� �-• If yes,volume pumped: /,P,5� ggallons—How was quantity pumped determined. /awrc in jMaj44, SCE .��k Reason for pumping: ��� _ TY;E 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/Aiternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) - -Tight tank Attach a copy of the DEP approval __..Other(describe): Approximate age of all components,date installed(if known)and source of information: Ianlz e3P% 19 7 x Y P SAS 1`3F Were sewage odors detected when arriving at the site(yes or no):N0 • 6 L Page 7 of I I OFFICIAL INSPECTION FORM-NOT FOIL VOLUNTARY ASSESSA'IENTS SUBSURFACE SE\VAGE DISPOSAL SYSTEM INSPECTION FOR 1 � PART C SYSTEM INFORMATION(cominucd) Property Address:_275 Midpine Road Cummaquid Owner: Russell LaPorte Date of Inspection: BUILDING SEWER(locate on site plan) 4 .; Dcpdt below grade: Materials of construction:_cast iron 40 PVC_other(explaur): '! Distance Gom private water supply well or suction fine: Comments(on condition of juints,venting,evidence of leakage,etc.): Jo• v�S �lC - suo t4fY( .e err -1��u /L�vs �'t►iriaoyA SEPTIC TANK: ✓(locate on site plan) Depth below grade. Material of construction:-Ae!�uncrete_metal fiberglass_pol}ethylene . _odrer(cxplain) _ If tank is metal list age:_ Is age confrrmcd-by a Certificate of Compliance(yes or no):_(attach a copy of• ' cenificatc) Dimensions: la5b I/o+r Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: . ,•• Scum thickness: ,, T Distance from top of scum to top of outlet ice or baffle: �t Distance from bottom of scum to bottom of outlet tee or baffle: f low were dimensions docrinincd:_ �gyc i,e} f�ur�n� , .� �G I✓l r 'C7�+aJw Comments(on pumping reconwtendations,inlet and outlet tee or baffle eondition,structural integrity,liquid levels) as related to outlet invert,evidence of leakage,e(c.): _ J,le.�- 6h/ i�,'�te.� j les .a-f-�•e�" w1� r+. �®e/ Cevte�i Q .. st+uw Goa( Aea t /C4.4L6,t. wa4•r j ,�,arf �..sr a� ? +�• OL� o2f �NtItJ 4 GREASE TRAP _(. t�ll r ,,x•'`rt; 'v. �+ a on site plan) Depth below grade:— Material of construction: concrete_metal Gbetglass_polyethylene_other k (explain): Dimensions: Scunt thickness: Distance from top of scual to top of outlet ice or bafmc: Distance from bottom of scum to bottom of outlet ice or baffle: Datc of last pumping: Conuncnts(on pumping reconunendatiotts,itslet and outlet tce or baffle eonditio:t,structural iniegrity,liquid levels as related to outlet invert,ecidcucc of leakage,ctc.): 7 r , ►gc8ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFOR]NUTION(continued) roperiyAddress: 275 Midpine Road Cummaauid )wncr: Russell LaPorzte ►ate of Inspection: (off FIGHT or HOLDING TANK:t4 Ipttank must be pumped at time of inspection)(locate on site plan) )cpth below grade: vlaterial of construction: concrete meta! fibc%lass polyethylene other(explain): Dimensions: -apacity: gallons Design Flow: gallons/day _ Mann present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Corruncnts(condition of alarm and float switctres,ctc.): DISTIUBUTION BOX: /(ifpiescnt must be opened)(iotate on site plan) Depth of liquid level above outlet invert: � Conunents(note if box is Icvcl and distribution to outlets equal,any evidence of solids canyover,any evidence of leakage into or out of box,etc.): ��� rs a�-+ec• rr.�a}y fe..si t,.4s n, 16c*bM ►►C o,+Jefi - ivD .Sa7dr, �s✓/s r9Ja_r , I'UDiP cunnlBEn: /V>(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Commcnis(note condition of pump cltambcr,condition of pumps and appurtenances,ctc.): Page 9 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 275 Midpine Road ummaqui Owner: Russell LaPorte Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): Zoocate on site plan,excavation not required) If SAS not located explain why: y Type leaching pits,number._ leaching chambers,number: leaching galleries,number: ✓leaching trenches,number,length: 1 leaching fields,number,dimensions: overflow cesspool,number: d innovative/altemative system Typetname of technology: - - -" Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): t Sod t.. " ,fir„ IVS, .Ssf-. A clit 1kf �..L�� T«k L,.41 A-o df-.' ---�Ler1oJS �01tvi=+aauiF CESSPOOLS: (cesspool must be pumped as past of inspectionxlocate on site plan) Number and configuration: Depth—top of liquid to inlet_invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:�/ locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICLAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 275 Midpine Road _Cummaquid owner: r e Date of Inspection: 6L-1141207 SKETC H OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or beachiharks.Locate all wells within 100 feet.Locate where public water supply enters the building. P • 11% STANK a - A-I b•Box I 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: 275 Midpine Road ummaqui ; Owner. RusselT LaPorte Date.of Inspection: 0D7 SITE EXAM Slope Surface water , Check cellar Shallow wells Estimated depth to ground water 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 ISO feet of SAS) Checked with local Board of Heald-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: a� C�no�.til x—,I.r .eltAA.*a,, c. ,,s ob4..o..e-d 16. LtC[lf�aow ,A—," Off' cSwnt 'Ltc U1?)u�U.�..n9r� i e i 11 CO.NMO.N-%VE.*%LTH OF MASSACHLSETTS _ EhECLTIVE OFFICE OF ENWMO,.%-mExTAI. AFF.AJRS DEPARTMENT OF ENVIRONMENTAL PROTECTION O\E n=R STREL^.BOS'I ON X-k 0210e 161 1 292-550%, TRU DT COX Secre:a-.Y ARGEO PALL CELLtiCCI DAVID B STR"HS Governor ' " Cotnauss:one- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTICATION Property Address:275 Mid-Pine Rd. Nameofownernnn Callabreese Cu maquid Address ofOwnar: Date of fnspection: g/410 p/ Narne of Inspects:(Please Prim ft. E. Robinson Sr. 1 am a DEP approved s erq inspectorp�w�to Section 15.340 of Title 5(310 CMR 15.000) Corrrpanyusme: Wm. E . Robinson Septic Service MafirngAddress: PO Box 1089, Centerville MA Telephone Number: 7 7 —8'7 7(� CER71RCATION 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 sew ge disposal systems. The system: asses Conditionally Passes f 'y _ Needs Further Evaluation By the Local Approving Authority Fails %] Inspector's Signature: a t Date: The System inspector shall submit a copy of this inspemion�repon 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 ttre system owner and copies sent to the buyer. if applicable. and the approving authority. NOTES AND COMMENTS DREE RECEIVED IWAR 2001 T N OF BARNS HEALTH DEPT. E rev_-;.se6 5/2/9E PaptIoriI h C: -^-trd o^Reward Panr• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIRCATIOII(continued) i Nop"Addresa,275 Mid-Pine Rd. , Cummaquid awner: Callabreese Date.of Inspection: INSPECTION SUMMARY: Check CA)B, C, o/ D: A. SYS*11 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. Indicat yes,no, or not determined(Y. N, or NO). Describe basis of determination in all instances. H "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 lattached)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 N 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 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 pipets). The system will pass inspection if(with approval of the Board of Health): broken pipets)are replaced obstruction is removed revised 9/2/96 Page 2of11 a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) PropentyAddress: 275 Mid-Pine Rd. , Cummaquid Owner: Callabreese Date of Inspection: C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing.to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303 f 1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. a= 2) S STEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS NCTIONING 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). 31 OTHER _ev1se-_ Page 3of11 • f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 275 Mid-Pine Rd. , Cummaquid °"r"ef: Callabreese Date of Inspection: D. SYSTEM FAILS: You mus indicate either "Yes" or "No" to each of the following: have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this termination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes N Backup of sewage into facility-or system component due to an overloaded orclogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LAR 3E SYSTEM FAILS: You mus 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 god 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 r 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-sea 5%2/5b PaRr4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM, PART B CHECKLIST Property Address: 275 Mid-Pine Rd. , Cummaquid Ownef: Callabreese Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No . Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for et 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. V _ 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. t/ _ All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. 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. f _ Determined in the field (if any of the failure criteria related to Part C is at issue,approximation of distance is'unacceptable) 115.302l311b11 ' The facility owner (and occupants,if different from owner) were provided with information on the proper-raintanaocs f SubSurface Disposal Systems. re' sec Page 9 of 11 l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION 'roperty Address: 275_.Mid-Pine Rd. , Cummaquid own er: Callabreese Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow:3 C d g.p.d./bedroom. Number of bedrooms(design):' Number of bedrooms(actual):3 Total DESIGN flow 3( 6 Number of current residents: s� Garbage grinder(yes or no):_c) Laundry(separate system) (yes or no):&a, If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use (yes or no): jV Water meter readings, if available (last two year's usage(gpd): 1 999-00 640,000 gal, Sump Pump (yes or no):A,C) 1 998-99 57,000 gal. Last date of occupancy COMMEN IAUINDUSTRIAL: Type of es ablishment: Design floN: qpd ( Based on 15.203) Basis of de 'gn flow Grease trap resent: (yes or no)_ Industrial W ste Holding Tank present: (yes or no)_ Non-sanitar waste discharged to the Title 5 system: (yes or no)_ Water met r readings, if available: Last dat of occupancy: OTHER: Describe) Last dat of occupancy: GENERAL INFORMATION PUMPING RECORDS andsure of information: System pumped as part of inspection: (yes or no)� O 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 lif known)and source of information: 1 7 �• Sewage odors detected when arriving at the site: (yes or no) rev.LseC 5/2 9.c Page 6of11 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Icontinued) 'roperty Address: 275 -Mid-Pine Rd. , Cummaquid owner= Callabreese Date of Inspection: /V/—p B ING SEWER: ILoc to on site plan) Depth below grade:_ Maier I of construction:_cast iron_40 PVC_ other(explain) Dista ce from private water supply well or suction line Diem ter Corn ents: (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK:_ (locate on site plan) Depth below grade: Material of construction: /concrete_metal_Fiberglass _Polyethylene—other(explain) If tank is metal,list age_ Is.age confirmed by Certificate of Compliance_ (Yes/No) Dimensions: Sludge depth: _4 •' Distance from top of sludge to bottom of outlet tee or baffler 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 bafflerp How dimensions were determined: 4 U L"!" f a 'omments: Irecommendation for pumping, condition of inlet and outlet tees or be les, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage. etc.) �d D a .s I Te .�!C �r✓� z )' w �2 l - Ai rSe§ 02 TA Ls Sl Z!�A J'2 GR E TRAP: (locate n site plan) Depth be ow grade:_ Material f construction:_concrete_metal_Fiberglass _Polyethylene_other(ezplain) Dimensio s: Scum thi kness: 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 est pumping: Comm nis: (reco mendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evide ce of leakage, etc.) revis'aC page 7or11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'roperty Address: 275 Mid-Pine Rd. , Cummaquid Owner: Callabreese Date of Inspection: Tl OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) liocat on site plan) Depth elow rade:_ P 9 Materia of construction:_concrete_metal_Fiberglass_Polyethylene_otherlexplain) Dimensi r Capacity gallons Design w: gallonsiday Alarm p esent Alarm I vel: Alarm in working order: Yes_ No Date of previous pumping: Comm nts: (condi ion of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_v (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence,of�s lids carryover, evidence of leakage into or out of box, etc.) - PUMP CH MBER:_ (locate on ite plan) ,. Pumps in w rking order: (Yes or No) Alarms in orking order(Yes or No) Comments (note con ition of pump chamber, condition of pumps and appurtenances, etc.) reViSeC 5/2/SE Page8orii SUBSURFACE_SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C .(SYSTEM INFORMATION(cortdnued) 'roperty Address: 275_ Mid-Pine Rd. , Cummaquid Owner: Callabreese Date of Inspection: `—/y,6 f 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: 1 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 hyd ulic failure, vel of pondic,g, damp Soil, conditi n of vegetation, etc.) D.�. .0 . . j C POOLS:_ floc- a on site plan) Numb and configuration: Depth-t p of liquid to inlet invert: Depth o solids layer: )epth of scum layer. Dimensio s of cesspool Materials f construction: Indication f groundwater: i flow (cesspool must be pumped as part of inspection' Comments: (note condi ion of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate o site plan) r _ Material of construction: ' Depth o solids: Dimensioas: Comme ts: Inote co dition of soil. signs of hydraulic failure, level of ponding, condition of vegetation, etc.) �%7 2, Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Noperty Address: 275 Mid-Pine Rd. , Cummaquid lwrw: Callabreese Date of Inspection: 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) y�Q � 1 ' � a( • ti ti .•� Ye-:_sec PagE,10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION lcon*w6dl ropertyAddress: 275 Mid-Pine Rd. , Cummaquid Owner: Callabreese Date of Inspection: IV—0 7 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 Estimated Depth to GroundwaterZ& Feet Please indicate all the methods used to determine High Groundwater Elevation: '(/ Obtained from Design Plans on record Observed Site (Abutting 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) p�� f revised 9/2/9E Page 11of11 I - V. No......�6..�.. '?jP�� ..... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF ,HEALTH ..... -.........0F..' ............................................................ Appliration for Diipuiittl Workii Towitrurtion "arAft - ' 1F• S � Application is hereby made for a Permit to Construct ( ) or Repair (4,4 an Individual Sewage Disposal System at: Location-Address or Lot No. • /�ie� Owner Addre s a l %!too-------------------------•--•---.....-------•----•-----•-- 50:.. 1>?_54-. + Ca �::. tar c? ..............._..... Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms................3...._........_.._..........Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons.....................--.---. Showers ( ) — Cafeteria ( ) A4 Other fixtures ............................ . W Design Flow............................................gallons per person per day. Total daily flow.......................................:....gallons. 04 W Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter..-----..--..... Depth................ x Disposal Trench—No.;................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No ----'-------- Diameter.................... Depth below inlet..................... Total leaching area..................sq. ft. Z Other Distribution box-( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1................ininutes per inch Depth of Test Pit.--................. Depth to ground water......................... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-----................... a -----------------------------------------------------------------------------------------------------------------------------------------••-•---------------- ODescription of Soil.........................................................--••----•-•--•---•--.....---------•-----------------------------------.....---•--......------------........--- x x ----------- ---- • --•---••. -------------•---•......---••---•-•----••- ---- ...... ---•••--- ---• ••• ---- ................... Nature of Repair or(Alterations-(Answer when applicable -x14#"_$.1 o'Po.� .CK/Pz . Agree ent: - r- - . The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT E 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in E operation until a Certificate of Compliance has been issued by the board of health. Signed....... . ... ....... ............................................... --- ........8(---•--.... Application Approved By--••-----------••---•-•.......-•--------------•- '�'�,. pate--�---•$-6 Date Application Disapproved for the following reasons-------------------------------------------------------••------------------------------------------------------- Date PermitNo--------------------------------------------------------- Issued........................................................ Date .I 1 No.........?6 'rrFs$�.... .......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . awn.............OF.... Appliratiun for Ropuoal Works Tonotrurtion "permit Application is hereby made for a Permit to Construct ( ) or Repair (- an Individual Sewage Disposal System at: ....:...- 75 m1C1,. (I-u mmrl Lrlc�......... .-----•............. •--........._......-----....._.._..........._...._. Location-Address or Lot No. •--•----•-•---• -•............. ---------- •--• ................. ,�} T•• d� Owner i ¢ i Addre�js V W Nt �� '�?.... .....................................� � IGetY8 d�NQe {RJC;, ,•_ {oYIat7G .....---__•.............................. ..a.. .. ___. ..................... Installer Address dType of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms................3.........................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures -------------------------------•-•--------------------'•------------------------------------------•-----------------•-•-•-------•...------...--------- w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length________________ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by......................................................................... Date........................................ 4 Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ----------------------------------••-----•------...._._...•----....••----•---•---•---------...............•-•----------•--•----.....•••---•------------------ 0 Description of Soil.........................................................-•-•-----••---•-----•---------------------•---------------...---------------------..._......--••...---••-••--- x w _ U Nature of Re airs or Alterations—Answer when applicable_.-�? s " '__t noca_ ............... . - r 1 I` uar.Q - . Agree ent: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE: 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed__: ,tcw �f .. _ ........ .........................._.......... .......................... tg Application Approved By................................................. __:- 'g -----------•--•--- Date Application Disapproved for the following reasons:---- •--------•---------•--• ---•-------------------•--------------------------•-------------•-------..._--•--- = = ------ Date PermitNo....................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH j 1 Gtsa.'?.................OF...�.......-ur>,5t�i ................:................. ..................................... CEnrtif iratr of Tompliana THIS , That the Individual Sewage Disposal System constructed ( ) or Repaired (- by- ': ..................r.............................................................................................................................. at........ ; - has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as escribed in the application for Disposal Works Construction Permit No.__._.___ _6_'._3_`s '_____.___ dated_--.---_--5-1-7. ____________________ 4THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARAN EE THAT THE SYSTEM VIAL F TI N SATISFACTORY. DXE-•-- --•-- _�-_ - -.. Inspector. l ..... 4 THE COMMONWEALTH OF MASSACHUSETTS � L���� e> sQ1C""' C % BOARD OF HEALTH 1b O F................,rn5 No....... F? �g� ------------------------------- FEE......�!5 ....... rt-pl�c,� w giovoo�l Marko Tonotrurtion "rrmit ... 4►r'C1 p . Permission is hereby granted--- .... _. .:. �4a G� ry-...... ... to ConolReit atindividuA Sewa isposal System Street , _ sc: as shown on the application for Disposal Works Construction Permit No.__.�_. .j_$ Dated..___________.. 2- ` .................................................. Board Health DATE............. ............ ..............................•-..........-------- FORM 1255 A. M. SULKIN, INC., BOSTON g Jr i a� No. 7 .�_ Fss.............................. THE COMMONWEALTH OF MASSACHUSETTS _ BOARD �y `R OF HEALTH O..�..............:......OF.....3,4 aS7, 13 ................................... ApplirFa#inn fat"Disposal Workii Tnnstrnrtinn rumit Application is hereby made for a Permit to,Construct-•(,K) or Repair ( ) an Individual Sewage Disposal System at: L°v�nm/� ......L®T -i S7 1..... .s ...P�ue.._`7e+v§�..=----•-•---....... wv� T-- ------------------•-•••-........-•---......_. Location-Address / Q r Lot No. , zslaN 'tie 46 0__!_.�.!!211_?.E�. . �R.t?�� �Ql.... ,�W47tZ Add Owneri . . ress a i Instal er• 41 Address dType of Building `` ' " Size Lot____________________ q. feet Dwelling�No. of Berooms?_.........______..........................Expansion Attic (k ) `Garbage Grinder (3C) Other—T e of Building No. of ersons________________________ ' Showers ' a � g.-----';;�------------------ P ---- ( ) — Cafeteria ( ) Otherfixtures ..............'............ -----•--•-•-----'-•-_------••••••--•_•-'-•-----•-••---•_•----..._-------•-•--'-•-•----•------•-••--•-•---•-----•••-----•-•-- W Design Flow......... ..........;7S.7__gallons per person per day. Total daily flow-------4�¢Q....................gallons. WSeptic Tanker Liquid capacity!S _.gallons Length................ Width_.....:'.__ "Diameter--._---,::_.____ Depth......_......... ft 3 saw encli—No..................... Width..................= Total Length.:.................. Total leaching''ar`ea....................sq. ft. rt No ____ __________ Diameter___._...._.___..____ Depth below inlet�_ �_,"3��_..._. Total leaching Other ft. Z Other Distribution box ( Dosing to �j '') ®�� ��•"/j2• _ 3 =�- j!6 S- a ' Percolation Test Results Performed by.____. _thin�r1.._. I N�..-•• ........ Date...._______'3`Z/_8_:......__.. ,.a Test'Pit No. 1----___�Q-___minutes,per inch Depth of Test Pit...... �______ Depth to ground water__L�10_!s!__.We (i, Test Pit No. 2................minutes-per"inch Depth'of Test Pit__-__l 2_`____: Depth to ground water_. Ad vIg'_&C- ---- -------------• •._... .-•---••_-----•-----•--_-... • -......................................................... p 0 3 4---f 2. Description of Soil: •'•'--_•---•�9=!�1t�_x���-�' : .�.. ------- D =•--'---'----------•----- ,x ............. .......................------------------------- --- •.. ------------•-••--....-----------_-_--- ..,-----••-••----___•_--•-••---___._.-----_-_---------•--•------•------•-. U Nature of Repairs or=Alterations—Answer when applicable_-:-__----:_.r:_:.................___ ___________________ _______________________________ ••-------------'--•-••-----------._..:-•--•--------•-------•---•--_•-•.'-------------........----•--_-•------....--_•_--_•_•'-•--_-•••-••-•...-_--•---•--••••-'-_-••-••••_-••-•-•'--'-•-...--•----_----•. Agreement: The undersigned agrees to install the aforedescribed Individual.Sewage Disposal System in accordance with the provisions of ITU -5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation-until a Certificat''e of Compliance has been issued by the o rd of health.;, y :. Sig 'd___. - ' . . .. •- ______.'---- Z3/ 7... Wi��—$ Date Application A roved'B t 7 •: G PP PP Y= •-'' at -----•--- Applieation Disapproved for the following reasons:................................................................................................................ ...............•--_••---••___-_____._.._...---•••----•••'--•-•-•-•-•--•--..._._•-•-•-----------•-•--•-•-. Date PermitNo......................................................... Issued-...................................................... Date 7� .i/ r No----------=--7 :.. Fps..Z. _...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH l��. ....................OF.... Allpliraa#ion for Diupuual Works Taustrur iurt jJamit Application is hereby made for a Permit to Construct (A) or Repair ( ) an Individual Sewage Disposal System at: to7 1Sl H,,> �� De1uC C- umrr�i9w�.� /-/TS ...................._...-----•--- - °• ....._----------.._....--- ------------------------...------ ---------------•--.....-------.....------- ----------- -------- -- --- Location-Address // --qr Lot No. - o��N �L ✓C=/1� .. fl tv�L�N Co l i�r�'G i/a_�............ ... 1—F-5 - --rl,^<_ilG y�AZ --•• Owner Address ati I , irA� N....._.../ c2rMovr;N---- Installer Address Type of Building - Size Lot.............................Sq. feet Dwelling—No. of Bedrooms..................................._--------Expansion Attic ( ) Garbage Grinder Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ------------------------•--------------•----•---•---...-•--•---•-•--•------•-------•--------•------------------------------•••--------••-•........---- W Design Flow......... .........4Ta7__gallons per person per day. Total daily flow........¢4_V_____________•._____gallons. WSeptic Tank—Liquid capacity�-59U__gallons Length................ Width................ Diameter................ Depth................ D_isposal,Tench—No_ ____________________ Width_..-_____._.__._.___ Total Length..__..______.______. Total leaching area.................... ft. __ Seepage Pit No......Z.-________ Diameter____________________ Depth below inlet_ ......... Total Total leaching area__ -----sq. ft. Z Other Distribution box ( K) Dosing tank' ( ) o�; /7�d - � _ 3- j�_ 76. S 6—4e-) Percolation Test Results Performed by-__-__ :............. .. ,I... a Date ---•• .....-=................. Test Pit No. 1........4---minutes per inch Depth of Test Pit...... _ '....... Depth to ground (s, Test Pit No. 2................minutes per inch Depth of Test Pit...... . _...... Depth to ground water... ............ --------------•--------------------------.....- O Description of Soil__________'----- a��M £� - "� 5 0, c,_ > /Z 6'�/'c r. �119 Aii� ....-••••--•----•-------------•....._........------•------•--.•----••-•••---•••-••----------=--•--•---•------------------•---•-•---••--------••-- W ----------------------------------------------------------------------------------------------------------------------------------• ---------------------------------------------------------------•-- U Nature of Repairs or Alterations—Answer when applicable------------------------- --------•--•-----------------------••------•--------------•----•---•----------------........_...---•----•--------------------------------------------------------•--•--•------•--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T IT LE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the,,board of health. Sig red.....t� N^ — L-=��.-�. l.......1�i 'j��' d ?� (.tJfa L S l 6 Date Application Approved B / __ (((' ,� _ --f 19ate Application Disapproved for the following reasons:...........................................................................---........... ...................... ..••-•--...-••••-•••..._._...-•-••----------••--•-•-••-------------•--•••.....--------••----•----------•----------------------------------------•-..................................................... Date PermitNo......................................................... Issued_...................................................... Date A's THE COMMONWEALTH OF-.-.'-.,MASSACHUSETTS _ BOARD OF HEALTH �Uw. ..............y.. OF..... -��'72�U5 �.?/ L ......... . ...........•_•................................... f�r�ifirtt�e f : u�t�li�a�trr THIS IS TO CERTIFY Tha evid . sSe a'e Da osal System constructed ()Q or Repaired ( ) �,//l, Installer / r at...........=-=•--y.5-.----1_-f•'f.d...........................................................r. Gn•"yrt�c r ..1•�c =- has been installed in accordance with the provisions of T -.TIE) 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No. __ .... ........... .______________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO TRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. r i� 1 DATE............... d•........... •---•------ -:• Inspector. -0--"-------------_--------•---------- THE COMMONWEALTH OF MASSACHUSETTS r BOARD OF HEALTH � !N. .................OF. . ? nJS. ►_ - =-----...._.......:---.:::_.._......... No._.......- •--••74-..... FEE.....:�--•/� Diupuuul Works 0-puuutrudWit Vamit Permission is hereby granted -5",t = == #� e4;._tv -- ' to Const uct ()4) or Repair ( ) an Lndividual Sewag Disposal System t StreeN/ as shown on the application for Disposal Worlts Construction Perm No..'--!__ .____ _ Dated__._.t�=_ y .7P........... !_ rl _ --------•-• -• Healh DATE-- " . "- FORM 1255 HOBBS & WARREN, INC., PUBLISHERS ,,,� TOWN OF BARNSTABLE L.�.CATION SEWAGE # VILLAGE Q7S M p►NC-_ ASSESSOR'S MAP& LOO'N OZZ INSTALLER'S NAME&PHONE NO. W C Rof iri-so J SEPEi C. 7-75-9 7"7!0 SEPTIC TANK CAPACITY 1, 000 t r i LEACHING FACELrrY: (type) Ic A C k tP%,-ewCk (size) SI X Z X(00 NO.OF BEDROOMS 2- BUILDER OR OWNER PERMTTDATE: g ib jets COMPLIANCE DATE: i 1 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by e t nay �.,ofiaav�' e� Eb, 3P e .L r , LO' CRTI'ON - SEWAGE PERMIT NQ. ) /. �_,' VILLAGE I N S T A LLER'S NAME g ADDRESS B U I L D E R OR OWN ER DATE PERMIT ISSUED r DATE COMPLIANCE -,ISSUED C�- � 3y y o `� ('� '� 11 ii � oiI 1 1 al S r '� ♦ �'' T .� C�'® z ,� � QIc� ��� TOWN OF STABLE LOCATION.. �� SEWAGE # VILLAGE ASSESS 'S MAP & LOT OQP Q NAME&PHONE NO. 1461e SEPTIC TANK CAPACITY LEACHING FACILITY: (type) C� (size) NO.OF BEDROOMS BUILDER OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 3 Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) l Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300&xt of leachin facil- ) / Feet Furnished by / ANC /r 0 L0C-AT 10.N SEWAGE PERMIT NO. -78 VILLAGE ) `� INSTALLER'S NAME & ADDRESS W it Ao Ikr*e Sys ova cle:VS 6,4,Y,5 cr4e 70 �n (,t�✓1 C s la BUILDER �-�OOR OWNER DATE PERMIT ISSUED �� �tf_ 7b' DAT E COMPLIANCE ISSUED /v _ 'e .b 1 i TOWN OF BARNSTABLE - UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION . MAP NO. �'; PARCEL NO. `)2- ADDRESS OF TANK: 27,E l it P' /A -0, G� VILLAGE: /77tV X tl U 1 C Numbfwr ! aft rw4wt / �/ MAILING ADDRESS ( IF DIFFERENT TY FROM ABOVE) : /� C U`"7 (V OI-7 1-Un ov U/ OWNER NAME: ,-� 0 /-/A/ : � 3 l C� (.A_.! A) PHONE. i INSTALLATION DATE: BY: INSTALLER ADDRESS: -CERT.NO. STANK LOC�AT I� re,a ��� v� ,� (ommopt s nc T^Nw &-ooAT I ON W S TH Pi¢OPCCT TO WU I LLD I NO) CAPACITY- �`TYPE OF TANK 5 7� '_ ! AGE /G> YRS. FUEL/CHEMICAL �'as TESTING CERTIFICATION C ] PASS C ] FAIL DATE LEAK DETECTION C 7 CHECK IF N/A TYPE/BRAND ZONE OF CONTRIBUTION C ] YES C !j NO DATE TO BE REMOVED / , FIRE DEPT. PERMIT ISSUED C I YES C ] NO DATE 4 CONSERVATION C I CHECK IF N/A DATE BOARD OF HEALTH TAG NO. C � I- DATE ., P,LEASE,,,S.PRO,V.I DE,,A_,5_KETCH. SHOW I NG THE TANK LOCATION ON THE BACK OF THIS CARD i `s BORTOLOTTI�CONSTRUCTION, INC. MORSAWN .,.�. " PARCEL 0• 0 ZZ SUBSURFACE SEWAGE'DISPOSAL SYSTEM I�PECTION FOR Address Prop ' Q fCfry oo G rDateof Inspec Map3 7 arcel�2 Z owner PART A — CHECKLIST c" CHECK IF THE FOLLOWING HAVE BEEN DONE: 8 PUMPING INFORMATION WAS REQUESTED OF THE OWNER,OCCUPANT,AND BOARD OF HEALTH. NONE OF THE SYSTEM COMPONENTS HAVE BEEN PUMPED FOR AT LEAST TWO WEEKS AND THE SYSTEM HAS BEEN RECEIVING NORMAL FLOW RATES DURING THAT PERIOD. LARGE C MES O E NOT BEEN INTRODUCED INTO THE SYSTEM RECENTLY OR AS PART OF THIS INSPECTION.' AS-BUILT PLANS HAVE BEEN OBTAINED AND EXAMINED. NOTE IF THEY ARE NOT AVAILABLE WITH N/A. E FACILITY OR DWELLING WAS INSPECTED FOR SIGNS OF SEWAGE BACK-UP. E SITE WAS INSPECTED FOR SIGNS OF BREAKOUT. SYSTEM COMPONENTS,EXCLUDING THE SAS,HAVE BEEN LOCATED ON THE SITE. JHE 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. SIZE AND LOCATION OF THE SAS ON THE SITE HAS BEEN DETERMINED BASED ON EXISTING INFORMATION OR APPROXIMATED BY NON-INTRUSIVE METHODS. 1/THE FACILITY OWNER(AND OCCUPANTS,IF DIFFERENT FROM OWNER)WERE PROVIDED WITH INFORMATION_ON THE PROPER MAINTENANCE OF SSDS. PART B — SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIAL n�^ No of Bedrooms _ No of Current Residents Garbage Grinder C�s Laundry Connected to System" A10 Seasonal Use NON RESIDENTIAL: . Calculated flow WATER METER READINGS,IF AVAILABLE: GALLONS Pu npin Records and Source of Infor on: SYSTEM PUMPED AS PART OF INSPECTION? A16 IF YES,VOLUME PUMPED — GALS Reason for Pumping: TYPE OF s3pm Septic tank/distribution box/soil absorption system Single Cesspool Overflow Cesspool Privy Shared system (if yes,attach previous inspection records, if any) Other(explain) Approximate age of all components. Date installed,if known. Source of information. e_ ego/ cl. SEWAGE ODORS DETECTED WHEN ARRIVING AT THE SITE? y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B — SYSTEM INFORMATION (Continued) SEPTIC TANK: Depth below grade Dimensions: Material of construction: Concrete Metal FRP _ Other} SludgEThickness pth �/ Distance from top of sludge Jy ttom of outlet tee or baffle Scum /�r Distance from Top of Scum to top of outlet tee or baffle ©uer TB Distance from bottom of Scum to bottom of outlet tee or baffle Comments: s /sue DISTRIBUTION BOX:merris: DEPTH OF LIQUID LEVEL ABOVE OUTLET INVERT L-oCom oe '4 PUMP CHAMBER: Pum sin workin order? Comments: SOIL ABSORPTION SYSTEM SAS IF NOT PRESENT,EXPLAIN: TYPE: _/ < Co nts: ov e CESSPOOLS: Number and configuration Depth-top of liquid to Inlet Invert Depth of solids layer Depth of scum layer Dimension of cesspoolI Materials of construction Indication of groundwater inflow(cesspool must be pumped) P Comments: PRIVY: Materials of construction Dimensions Depth of solids Comments: v SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM s J PART B — §) TEM INFORMATION (Continued? SKETCH OF SEWAGE DISPOSAL SYSTEM: INCLUDE TIES TO AT LEAST TWO PERMANENT REFERENCES,LANDMARKS OR BENCHMARKS. LOCATE ALL WELLS WITHIN i00' G _ DEPTH TO GROUNDWATER: DEPTH TO GROUNDWATER METHOD OF DETERMINATION OR APPROXIMATION: 6�/0 %cr/ R x�: y � of as, '�`�r �.-x{ �' �; �sx:'�Y�� 1: � .+,. :.,� $ �:• ¥2"_ P : ' � y ;�,S'e . t - z r r Y �:Yw,n"'kr-� w.a 'Y�.�,t•x "+h "' -' t4, r� ..a r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C — FAILURE CRITERIA �/ (Indka6e Y—yes N-no ND—not dotermh�ed.Describe basis of determination.If Nud determined',eplain why not)) /!/ Backup of Sewage into Facility? Discharge or pondirig of effluent to the surface of the ground or surface waters? i I. A/ Static liquid level in the districution box above outlet invert? I y r��4rj r Liquid depth inrmesVpOet; 6"below invert or available volume, 1/2 day flow? ,Required pumping 4 times or more in the last year? Number of times pumped �!V Septic tank is metal?cracked?structurally unsound?substantial infiltrationl substantial exfiftration? hI tank failure imminent? 77 i Is any portion of the SAS,cess ool orprivy, below the high groundwater elevation? P 9 i Within 50 feet of a surface water? Within'100 feet of a surface water supply or tributary to a surface water supply? --/1� Within a Zone I of a public well? Within 50 feet of a private water supply well? Within 50 feet of a bordering vegetated wetland or salt marsh (cesspools&privies only, not the SAS)? Al- 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,amonia nitrogen and nitrate nitrogen. PART D CERTIFICATION INSPECTOR: ROBERT J. BORTOLOTTI ADDRESS: 765 WAKEBY ROAD MARSTO NS MILLS COMPANY: BORTOLOTTI CONSTRUCTION INC: MA 02648 (508) 771-099 CERTIFICATION STATEMENT I CERTIFY THAT I HAVE PERSONALLY INSPECTED THE SEWAGE DISPOSAL SYSTEM AT THIS ADDRESS AND THAT THE INFORMATION REPORTED IS TRUE,ACCURATE AND COMPLETE AS OF THE TIME OF INSPECTION, THE INSPECTION WAS PERFORMED AND ANY I RECOMMENDATION REGARDING UPGRADE,MAINTENANCE AND REPAIR ARE CONSISTENT WITH MY TRAINING AND EXPERIENCE I IN THE PROPER FUNCTION AND MAINTENANCE OF ON—SITE SEWAGE DISPOSAL SYSTEMS. CHECK ONE: I HAVE NOT FOUND ANY INFORMATION WHICH INDICATES THAT THE SYSTEM FAILS TO ADEQUATELY PROTECT PUBLIC EALTH OR THE.ENVIRONMENT AS DEFINED IN 310 CMF 15.303. ANY FAILURE CRITERIA NOT EVALUATED ARE AS STATED IN THE'FAIWRE CRITERIA°SECTION OF THIS FORM. I HAVE IN THAT THE SYSTEM FAILS T PROTECT PUBLIC O ROTEC HEALTH AND THE ENVIRONMENT AS DEFINED IN 310 CMR 15.303. THE BASIS FOR THIS DETERMINATION IS PROVIDED IN THE'FAILURE CRITERIA'SECTION OF THIS FORM. INSPECTOR'S SIGNATURE: `DATE: 319� I ORIGINAL TO SYSTEM OWNER,COPIES:BUYERapplicable).APPROVING AUTHORITY -77 f off (- _,,/ cl 2 - - 2 s 3 ` _ 3 94 q ( �TQP , DF FOUND 7 /OY— �3 � -_— j5 EL � tl�paS�o �'tQ ►� aTG t1Evss�,} 6 ' 29b SLOPE C?V�R LEACHING AREA g2 .6 T'r 4s f, a 'i _ __ ► ._ ! 8 DtA. CONCRETE C0 `ERS 98 s� . 7 8 DIA. C• O RFTE COVERS �' - -'8 r� 1 -TIB" fl f A CC NC R I�T E EX; RINGS J�O,���• _� _.. ._._.__. _ --- ----- —.._._ ---- ^'" `_. /F l�' �/A-- 1S� �j�An� L r�F-arc'; - .j 1 ..� p 1 —211C OVER I -3/8 ------�- i 1 83 I WASHED ,STONES 12 EIV � ► �r CL�/ 8 (o- ti�b �JRr��e __. 1 ? t 4' i Ld -Lev, Dff� W/ 6 SUMP lain.e , { �a `'` ' '� n 1.4 ib ! a b ��I I 1/5 WASH D STONES 15 v FEF x...D E R rH b rl r / 1,)N �4 R �A�.►o �-'�R t � -tr o F_r rr o �- �1`-•-r•c.�'+. Ac �? W I 0 0 3 SDO GA P ,A � .. g= � 2 �;��rF JJ Job ►04 ►aZ Ali Ohl 44LLIK oe SEPTIC TANK- .. . j - WITH CAST � - � �-�- ..'" G �.t ,. , .; ' �/ - ` AN OUTLET l'S PER TITLE INL-ET D 0 AROUND SIZE : /o �oti� K �- ✓, r '.� �.�, ,:. / - ` 4� A�L RO ND 37 �v t t o 0j0 � �. � 3 PRECAST L. E,��HIN{� SIZE 4 '�-4 ' ` 4!-.. Cq vt--e a� _ _. - _..._ .._.-_ ......,...._-......_, :_._...._._. ..LL� ..,._. .-_.,._„_. ..•_ ..:.._S - 2 ENO' E!/ �c. /✓i"G'h�. ��,G F f,. SYSTEM DESIGNED TO ' TOWN OF .� ,� r1 RED ULATIONS `—`1 , , t S �TiL Tnl ri 4 AND STAT E T17L E . �Z FOR ,SUBSURFACE DISPO AL OF SEWAGE � NOTE, Y , \S og �IIEDUL E 4C PVC SEWER PIPES t o-F �zL15 I- ALL PIPES SHALL BE SC, , 2--ALL PfPES SHALL BE SLOPED 114" PER FOOT /W/N. EXCEPT FOR THE FIRST 2 FEET OUT OF THE B W H ShALLSE LEVEE f Y r � \ 3 - DESIGN FLOW— 4 � EDROOMS AT lf0 6AL1D Y PER BR = 44- L GAL DAY W y I SEPTIC TANK SIZE 440 X J 8&>G :USE 1 s00 ,� N — GARBA6� GRIN& R \ _ EACPINc sY�rEn� : USE 3 - 4,x 4 � �, -rc� F) r EFFECTIVE AREA , SIDES ; 12±Zo �- a L , d� 3. . r x, . �. _ Z7 f-A L (2 B O T Tr M : � � z � o; -��-Q�-_ � =��- 24� :��� 2 4� - _ . r TOTAL R EGUIR-E D r LO W. 44 o X / 6 G a_W/_ GARBAGE C�RIND � RES ER�� F — - - LOW ' 7&7 �J _ 11�� GA�DAY , - . �� __ "!_ __ —__ 1 .__vim ..__ F _._ ..•• ; \ ,� { ! -_, ?" _: '/t a. ►'" Sri^ _ ! " I j - -- \�--T ` ` � °— j'L-'�' 24 1`2 \10 i!c� .` �' Pr t7 R O P r T '�_...__�W NE r o N nJ.�, _ .__ ��v �L A . . VJ a L S N y. _...._-- ''ram y "'!lJ • 'ra /9/Lrlou f� — - ___L..........r._,..._.......,raw....+a-_...,w+=,e_.....rrvn.wr.....-,... ._.,....w..-w.. ,,.. .