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HomeMy WebLinkAbout0233 OAKMONT ROAD - Health 233 OAKMONT ROAD, BARNSTABLE 1 A= 334 059 d 1 I O - \ k PLUM STREET, LOT 17 W.BARNSTABLE A= 196-17 l a i i s COMMONWEALTH OF MASSACHUSETTS, z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS Y a DEPARTMENT OF ENVIRONMENTAL PROTECTION p o 350 MAIN STREET q WEST YARMOUTH,MA 508-775-2800 ` TITLE 5 a OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM• ti - C• PART Aq r CERTIFICATIONWCD MAP 334—PARC 059xq Property Address: 233 OAKMONT DRIVE CA i�p CUMMAQUID,MA 02637 r Owner's Name: PRICE,WARREN ` Owner's Address: 233 OAKMONT ROAD _ CUMMAQUID,MA 02637. - Date of Inspection MAY 23,2005 Name of Inspector:(please print) JAMES D. SEARS Company Name: A&E Canco Mailing Address: 350 Main Street West Yarmouth,MA 02673 Telephone Number: 508-775-2800 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority — Fails Inspector's Signature: Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to die system owner and copies sent tot he buyer,if applicable,and the'approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future un Jer the same or different conditions of use. Title 5 Inspection Form 6/15, '000 1 Page 2 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 233 OAKMONT DRIVE CUMMAQUID,MA 02637 Owner: PRICE, WARREN Date of Inspection: MAY 23,2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: d _ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: N/A _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined" please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health)" broken pipe(s)are replaced obstruction is removed ND explain: Title 5 Inspection Form 6/15/2000 2 I ' ' Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 233 OAKMONT DRIVE CUMMAQUID,MA 02637 Owner: PRICE, WARREN Date of Inspection: MAY 23,2005 C. Further Evaluation,is Required by the Board of Health:N/A _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety,or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CAM 15.303(1)(b)that the system is not functioning in a manner which will protect public health safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or 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 public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Title 5 Inspection Form 6/15/2000 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 233 OAKMONT DRIVE CUMMAQUID,MA 02637 Owner: PRICE, WARREN Date of Inspection: MAY 23,2005 D. System Failure Criteria applicable to all systems: N/A You must indicate"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool -- Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in pits is less than 6"below invert or available volume is less than%day flow �— Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone 1 of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) NO (Yes/No)The system fails. I have detennined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: N/A To be considered a large system the system must service 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:Il of a public water supply well. If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system is failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CUR 15.304. The system owner should contact the appropriate regional office of the Department. r Title 5 Inspection Form 6/15/2000 4 r Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 233 OAKMONT DRIVE CiIMMAQUID,MA 02637 Owner: PRICE, WARREN Date of Inspection: MAY 23,2005 Check if the following have been done. You must indicate`Yes"or"no"as to each of the following Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? if Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out? ✓ Were all system components,including 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)has been determined based on: Yes No ✓ Existing information. For example,a plan at the Board of Health. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[31 G CMR 15.302(3Xb)] Title 5 Inspection Form 6/15/2000 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 233 OAKMONT DRIVE CUMMAQUID,MA 02637 Owner: PRICE, WARREN Date of Inspection: MAY 23,2005 ` FLOW CONDITIONS RESIDENTIAL.( Number of Bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CUR 15.203(for example: 110 gpd x#of bedrooms: 440 Number of current residents: 2 Does residence have a garbage grinder(yes or no): - YES Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): YES Seasonal use(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no) NO Last date of occupancy: PRESENT COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CUR.15.203): 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 Title 5 system(yes or no): , Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: N/A Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system i' Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attach copy of the DEP approval Other(describe).- Approximate age of all components,date installed(if known)and source of information: 1986 Were sewage odors detected when arriving at the site(yes or no): NO Title 3 Inspection Form 6/15/2000 6 f • OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 233 OAKMONT DRIVE C JMMAQUID,MA 02637 Owner: PRICE, WARREN Date of Inspection: MAY 23,2005 BUILDING SEWER(locate on site plan): N/A Depth below grade: Materials of construction: Cast iron _ 40 PVC other(explain) Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK(locate onsite plan): Depth below grade: 7' Material of construction: concrete metal fiberglass polyethylene _ other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000-GALLON PRECAST Sludge depth: 18" Distance from top of sludge to the bottom of outlet tee or baffle: 12" Scum thickness: 4" ` Distance from top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How were dimensions determined: ASBUILT&TAPE Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): TANK AT WORKING LEVEL,COVER AT 2'.INLET BAFFLE-OUTLET TEE. NO SIGN OF OVER LOADING OR LEAKAGE. TANK NEEDS TO BE PUMPED. + GREASE TRAP(located on site plan) N/A Depth below grade: Material of construction: concrete metal fiberglass polyethylene other (explain): Dimensions: a 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(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): a Title 5 Inspection Form 6/15/2000 7 :�F Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 233 OAKMONT DRIVE CUMMAQUID,MA 02637 Owner: PRICE, WARREN Date of Inspection: MAY 23,2005 TIGHT or HOLDING TANK: N/A (tank must be pumped 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(yes or no) Alarm level: Alarm in working order(yes or no): Date of last pumping Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.,): D-BOX IS 6'BELOW GRADE. BOX IS CLEAN&SOLID,ONE LINE IN—ONE LINE OUT. NOTE:D-BOX INSPECTED WITH CAMERA. - PUMP CHAMBER: N/A, (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.): i .p } Title 5 Inspection Form 6/15/2000 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 233 OAKMONT DRIVE ' CUMMAQUID,MA 02637 Owner: PRICE, WARREN Date of Inspection: MAY 23,2005 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: 2 leaching chambers,number: leaching galleries,number leaching trenches,number,length leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) LEACHING IS TWO 1000-GALLON PRE CAST PITS WITH 2'STONE,COVERS AT 16"—12"WATER, STAIN LINE AT 18". NO SIGN OF OVER LOADING OR SOLID CARRY OVER. CESSPOOLS: N/A (cesspool must be pumped as part of inspectionX locate on site plan) Number and configuration: . _ Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: _ Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.): PRIVY: N/A (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.) Title 5 Inspection Form 6/15/2000 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 233 OAKMONT DRIVE CUMMAQUID,MA 02637 Owner: PRICE, WARREN Date of Inspection: MAY 23,2005 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 1� q` i Page 11 of 11 - OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) - Property Address: 233 OAKMONT DRIVE CUMMAQUID,MA 02637 Owner: PRICE,WARREN Date of Inspection: MAY 23,2005 SITE EXAM Slope Surface water Check cellar Shallow wells ' Estimated depth to no groundwater, 14 feet" Please indicate(check)all methods used to determine the high groundwater elevation: Obtained from system design plans on record-If checked,-date of design plan reviewed: �— Observation site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain; Checked with local excavators,installers-(attach documentation Accessed USGS database-explain: You must describe how you established the high ground water elevation: TEST HOLE AT 14'NO WATER. TEST HOLE 4'BELOW BOTTOM OF PIT: BOTTOM OF PIT AT 10' BELOW GRADE. 1 - goTM Title 5 Inspection Form 6/15,2000 11 r� 61 BORTOLOTTI CONSTRUCTION, INC. l9'9i9 765 WAKEBY ROAD,MARSTONS MILLS,MA 02 8 508-771-9399 508428-8926 FAX: 508428-9399 N~ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO PART A CERTIFICATION Property Address: oG Date of Inspection:/O /J Inspector's ame: Own is Name and Address: , .. CERTIFICATION STATEMENTe I certify that I have personally inspected the sewage disposal system'at this*address and that the informa- tion reported below is true,accurate and complete as of the time of inspect The inspection pection was per- formed based on my training and experience in the proper.function.and maintenance of on-site sewage disposal/stems. The System: ;. Passes Conditionally Passes • fl; Needs Further E onaB ;ocal Aproving Authority .' Fails Inspector's Signature: Date: 0 The System Inspector shall submit a copy of this inspection report to the Approving authority within thir- ty(30)days of completing this inspection. If the system is a shared system or has a design now of 10,000 gpd or greater, the inspector and the system owner shall submit the report to'the appropriate regional office of,the 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: A)SYS i PASSES: ` I have not found any information which indicates that the system vtoiates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated j below. B)SYSTEM CONDITIONALLY PASSES; f One or more system components need to be replaced or repaired. The system,upon comple- tion of the replacement or repair, passes inspection.., Indicate yes,nor,or not determined(Y;N,OR ND). Describe basis of determination in all instances. If "not determined",explain;why not: The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or exfiltration,orltank failure is imminent. The''system will pass inspection'if the existing sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. `Sewage backkup 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): r. (1 a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) w Broken pipe(s)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'"` 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 THAT THE SYSTEM IS NOT FUNCTIONING:IN A MANNER WHICH WILL PROTECT THE PUBLIC CHEALTH•AND SAFETY AND�THE-ENVIRONMENT: Cesspool or privy is within 50 Feet of a surface water Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a-salt marsh. 2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND'PUBLIC WATER; SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS'FUNCTION- ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is withini100 Feet to a surface water supply or tributary to a surface water supply. The system has aseptic tank and soil absorption system and is with a Zone I of a public' { water supply well. 3 ;; The system has a septic tank and soil absorption system and is within 50 Feet of fiprivate* water supply well. The system has aseptic tank and soil absorption system and is less than 100 Feet but 50 -- Feet or more from a private water supply well,unless a well water analysis for6606rin','7,' bacteria and volatile organic compounds indicates that the well is free from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to oc less f than 5 ppm. D)SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CNIR 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 ° a . Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent 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 clog= :. .god SAS or cesspool. • . . . r 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 1!1UT due to clogged or obstructed pipe(s). Number of times pumped ' 2- f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A r CERTIFICATION (con(inued) ' Any portion of the Soil Absorption System,cesspooI 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. Airy 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: Theifollowing criteria apply to a large system in addition to the criteria above: t +' The design flow of a system is 10,000 gpd or greater(Large System)and the syttem,is wsignificant threat to public health and safety and the environment because one or more of the following` conditions exist: The system is within 400 Feet of a surface drinking water supply - +� The system is-within 200 Feet of a tributary to a'surface drinking water supply The system is located in a nitrogen sensitive area Interim Wellhead Protection Areax"�'' =< (IWPA)-or a mapped Zone Il of public water supply well", A"'�` ar t^r , r r, The owner or operator of any such system shall bring ithe system and facility into full compliance with'the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please'consult the local`.'` Y regional office of the Department for further information. s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B -� CHECKLIST "Check if the,following have been done: . , t/Pumping information was requested of the owner,occupant,and Board.of Health. ✓.None of the system components have been pumped for atleast two weeks and the system hail` ,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. _iL_lAs-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.: `r ✓The system does not receive non-sanitary or industrial waste flow:'+ "'; ✓.The.site was inspected for.signs of breakout. systed1components;excluding the Soil Absoiptibn System,have been located on site. ✓The septic'tank manholes'were uncovered,opened,and theinterior of the septic taawas'in - '- 1 spected for condition'of bafllesv tees,material of constiuction dimensions;depth of liquid, j 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 or approximated by non-intrusive methods. -3- RIai j SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) v The facility owner(and occupants,,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION i / FLOW CONDITIONS RESIDENTIAL.- V Design Flow: D Ions Number of Bedrooms:_y Numbcr of Current Residents: Garbage Grinder: Laundry Connected To System: Seasonal Use: Water Meter Readi s,'if vailable: Last Date;of Occupancy CO MER AiAND 1ST IAL_,46' Type of Establishment } Design Flow•: aallons/day.,<Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Xv ^ System Pumped as part of inspection:�QQ_ If yes,volume pumped: ° I_!+, "t Ions ' Reason for pumping: TYPE OF SYSTEM: , Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous,inspection records,if any) Other(explain): AP ROXIMATE A E of all compo ents,date installed(if known)_And source of information: SeiwE&i odors detected when arriving at the site: . ID -4- : . .. i SUBSURFACE SEWAGE`DISPOSAL SYSTEM INSPECTION FORM .. . ^.PART C l GENERAL INFORMATION (continued) SEPTIC TANK. I/ i 0� ' • �? r Gc��G02`w_ Depth below grade: Material of Construction:�Cconcrete metal FRP_Othec (explain) t Dimisions: Sludge Deptlt:� A Scum This ness: Distance from�top of sludge to bottom of outlet tee or baffle: 301 Distance from bottom of scum to bottom of outlet tee or baffle: D ' Comments:(recommendation for pumping,condition of inlet and outlet tees or baflles,.depth of liquid level in relatio outlet invert,structural integrity,evider a of leakage,,etc.) a 6L-/60a - alota GREASE TRAP:_ Depth Below Grade: Material of Construction: concrete metal FRP Other (explain) — Dimensions: ScuinThickness: Distance from top of scum to top 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.leakage.etc:);" '_-< " :, ,_;a TIGHT OR HOLDING TANK: Depth Below Grade: Material of Construclion: concrete metal FRP Other(ex lain)p. , Dimensions: Capacity: gallons Design Flow: Rallons/day Alarm Level: _ - ,.i Comments: (condition of inlet tee;condition of alarm and float switches,etct) DISTRIBUTION BOX: ✓ , . {' Depth of liquid'level above outlet invert: Comments:;(note if lAvel and distribution is equal,a idence solids carryover, evidence of leakage into or out of box,etc.) PUMP CHAMBER; t { Pump is in working order: w. Comments: (note condition of pump chamber,condition.of pumps and appurtenances,etc:) • �'A lkil n�' . ay ir SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (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: Type: Leaching pits,number:_6�_Leaching chambers,number: Leaching galleries,number: Leaching trenches,number,length: Leaching fields,number,dimensions: Overfiow cesspool,number: Comments:(note condition of soil,signs of hydraulic failu level of ndin ,co ition of vegetation, . etc.) - d. / CESSPOOLS:, Number and configuration: Depth-top of liquid to inlet invert: , >„ Depth of solids layer: Depth of scum layer: Dimensions of Cesspool:_ i Materials of construction: Indication of groundwater: Inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soilk,signs of hydraulic failure,level of ponding,condition of vegetation,, etc.) PRIVY:_dQ Materials of construction: • Dimensions: Depth of Solids: Comments:(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) . .., G ' f t " 'SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM } PART C SYSTEM INFORMATION (continued),.- SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks: t Locate all wells within 100 Feet. 01".. ( DEPTH TO GROUNDWATER: ' Depth to'groundwater:_ �S Feet Method of Determination or App oxi lion: t 7- TOWN OF BARNS LE LOCATION - SEWAGE # Vn.LAGE ASSESSOR' MAP & LOT �h�5PFC ,PS i NAME&PHONE NO. SEPTIC TANK CAPACITY C�, IGvy�-/OG� G�. `• LEACHING FACELITY: (type) (size) /OGD -42,64 NO.OF BEDROOMS BUILDER 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 w yy c�� qq TOWN OF BARNSTABLE LOCATIO^? .9-3 3 C 41rm j�7 /0 SEWAGE # VILLAGE e U el A— /1-IQ U/2) n ASSESSOR'S MAP & LOT 3 3 O /�S�S NAME& PHONE NO. 0 SEPTIC TANK CAPACITY S � ti S�FC l LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER OR OWNER 5-U,, ��C PERMH DATE: $ d� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) - Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished,by cc�� � F �'° � " �,� �� � ���6 o t o ' ASSESSOR'S ,MAr NO.-� PARCEL cr L0CAT-ION _ SEWAGE #ERMIT NO. LOT 21 041c"DouT 233 96 —(,24 iLLAGE tetJMr�t�QcJ��D WG15 � Ct1KU�tpt!►D , jI, MSTA LLER'S NAME i ADDRESS ` &gam , e)()ie Co 1uc. � - e UILDER OA OWNER bm MA a u I b A,S S DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 1 FRONT 2V 4 i 0 O)S K K/1 © U ice!T RD THE COMMONWEALTH OF MASSACHUSETTS a BOARD OF HEALTH .............0F.......1� 5T�1 ...................................... Allp iratiou for Dhopwial Works Tomitrurtion Prrutit Application is hereby made for a Permit to Construct (tom or Repair ( ) an Individual Sewage Disposal System at: .....!�lGNlr�ivT Location-Address r No. yw �/_ /-,!p G-,�-,�� - 42 Fox Run,, T�opsflelc� assa_chusetts 01983 ......... ...........__........ .......... ....... .•..... .._......._............-- wner Address 2�. 6 iyk C 0 t'u C /L��4 T w STkr. . lZ.n (J--- Installer Address W Type of Building .� Size Lot.. _.9 ��.....-Sq. feet ,., Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder (L--� '4 Other—Type e of Building No. of persons............................ Showers Gr YP g ------•--•-----------•-•-•-- P ( ) — Cafeteria ( ) a' Other fixtures ................................. . W Design Flow.........�'✓-.:.........................gallons per person per day. Total daily flow............._3..-�..� ....................gallo y gallons. WSeptic Tank—Liquid capacity__�s� .._..gallons Length.. .G...... Width..4 _..__. Diameter................ Depth_.-5 --.. x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area.....................sq. ft. Seepage Pit No......... ........... Diameter....... Depth below inlet..... ........ Total leaching area....1�.9_-_5?.sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by..... �!^! a..._.C:._.. ................ Date..T,!C-.z7__-19BS. ,aa Test Pit No. 1..4..6-__-minutes per inch Depth of Test Pit----69.......... Depth to ground water....... ............ Test Pit No. 2...15�.A....minutes per inch Depth of Test Pit....! .".... Depth to ground water........................ ....................---...................................................................................................................................... 0 Description of Soil...... ¢z" WooD Le?.!2'.7_._.-$,•S�3-S&>[- 42'= e4' �A✓,S�.� 1.✓s� --•----- -•--------••..•--• ----•----------------••---•-•-•-•-•-•--•...... W ----•-•--------------------••-•-•............--•••-•-••-•••-•-••••--•............••-••...••••--•-----•--•---••-•--•-••-•...•••••••--•-••-•-...--•-•----••-••-•-•••••-•--••-............------.......... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... Agreement: Th a dersigned agr es to install the aforedescribed Individual Sewage Disposal System in accordance with the pro-is' ns of TITLi; o he State Sanitary Code—.The undersigned further agrees not to place the system in operat" until a Certifi to o Complliance has b en ' sued Ay the board of a th. q ne _ _ a 1986 Appli lion pr,ved�B ._.. ... """ ----.•......�/ Date Ap ication Di pproved for the following ons:..............................----•------•-----•-••----••••••--•-•-----••--------•••......•--•-._......-•-•-- '6Date t,„! PermitNo......................................................... Issued...................................... Date -���i No........................ Fizz......................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............. ..........._OF.............................. Appliratioo for Ui,spouttl Works Tonstrurtion rrmit Application is hereby made for a Permit to Construct (L,- or Repair ( ) an Individual Sewage Disposal System at: G..71c�7vni7 � � .. Location-Address .%t�� J. /-/I-2� - - 42 Fox rung, ToPsfie14' Massachusetts .-01983.. Owner Address W Installer Address d Type of Building Size Lot... ..................Sq. feet V Dwelling—No. of Bedrooms............................................Expansion Attic ( } Garbage Grinder (L-f Other—T e of Building No, of persons........................... Showers a YP g ---------------------------- P - ( ) — Cafeteria ( ) dOther fixtures .-------•-----•-------••------------•--•--------------•-•-•------------------•----••--•-•--•---•-••-••-•----•------•--._....._........_....••....---- W Design Flow.........- _......•..................gallons per person per day. Total dail flow...._.___.__-5 .......gallons. WSeptic Tank—Liquid capacity._�9.gallons Length._. G_.... Width.._`'_.. ��. Diameter................ Depth_._ x ,Disposal Trench—No..................... Width.................... Total Length............ _..... Total leaching area............._..sq. ft. Seepage Pit No.......3.._..._.__ Diameter....... z_ Depth below inlet......' ...... Total leaching area.._. el ft. Z Other Distribution box ( ) Dosing tank ( ) '-' Percolation Test Results Performed by....... D1�' !?.....�:..��................... Date..` �''lG. 27 W •--••••••.•.... a Test Pit No. I...i5�.._(-__-minutes per inch Depth of Test Pit..... ........ Depth to ground water....... :- -----. Lz, Test Pit.No. 2...G..G....minutes per inch Depth of Test Pit....�a�....... Depth to ground water........ ............ W •-••--....•••--••-••••••---•••--•----•---------•--••••-••--•------•.....----•-.....••••..:_......--•....................................... D Description of Soil......0,,__-4�.._w"o0 �,� ( Sri?-SviL 4-Z'= e4 E i�vG S�-,.� G✓.rr✓ -----------•--------------•---•----------•-----------------------------------------------------•---•--•--------•-----------•---•--- W VNature of Repairs or Alterations—Answer when applicable............................................................................................... -•-------•------------•--------•----•----------------------------------------•--------•--•--•----•-----------••--------------------•---------------------•-------------------------.._...----••......•- Agreement:, Theo�tindersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITI.L 5 of,& State Sanitary Code The undersigned further agrees not to Y place the system in operation'Until a Certificate of/Compliance has been issued by the board of health. y f �S_ipedA ._ ........-•---•.......................... •..._.._......-•--------••-- ......--••--•-•----- •..._.... March 3, 1986 �� �: Dat A lication, roved B 1 �f� � PP P Y- T... ; r �Dat� b Application D sapproved for the f ollowing r ons:--••---•-•--•------••......... ........••• --•-•-----•-•--••-••-•-••--------••-••------------••----•-••- - yf -------------------------------------------------------------------------------------------------- l� Date PermitNo....................................................... Issued..................` ..................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH I../n.............OF........ - .Ti .....l3GL'................................. (Irrtifiratr of Tantpliattre THIS TO-CERTIFY, That the Individual Sewage Disposal System constructed (c.�' or Repaired ( ) by-...._... -••-• -a-•--.....Z11...........................••_.....................................---•••...--••••-••.....------......-•-........•••..._...• -----••-- In �J_ �~� has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code aVVescrVib t the application for Disposal Works Construction Permit No.___..` _^.__ .__ dated..............9Z_` ��..__._. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARAEEAT THE SYSTEM WILL FUNCyTI0,N SATISFACTORY. , �. �. DATE.......................... •.---•- ................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 7`oln��i 8� �5 j�1���4 /,Z70 00 � ,;A.........................................oF............_.... ...-- No......................... FEE.....•••••••............ �i��o�ttl ork� �unnfrttr#iun ��rrmit Permission is hereby granted.................... • .............................................................. 2 to Construct ( v} or Repair ( ) an Individu Sewage Disposal Syst 41 atNo...........................•----••---••----•--.......-------•=--...------------.........---••----••---•---------•-----------._..----•---...---•-•---•--•••••.----- •- /'� ,Streetas shown on the application for Disposal Works Construction ermit No....... ........... D ed.._.._.._ . . .-... 4 � P- BoarcTof Health f FORM 1255 A. M. SULKIN, INC., BOSTON r AI'I'L] . ON FOR PERCOI,AT10N TEST AND OBSERVATION PITS LOCATION /t O—tZ �D�'l,CtiiO�/ �UfIQ _ NO. 4335 VILLAGE CJ�/.�� DATE APPLICANT A92 C/-//] I ,F S' &79A/4 JR FEE tADDRESS (Non-refundable) TELEPHONE NO. ' ENGINEER _TELEPHONE NO. �d Z-2.Z G;G DATE SCHEDULED i (APPlicant' s . signature) . . . . • . . 0 0 0 0 0 0 . O . O O 0.0 0 . • O . . : . 0 0 0 . 0 0 . ... . . . . 0 . . . • . • . 0 .•. . . O . . . . . . . . • . 0 . O . . . 0 0 . O . . . . . . �A / SOIL LOG /SUB-DIVISION NAME � ;,t z D[��V�t% /1LL 1 G,E. DATE e7, i9 I� TIME /U,',3J EXPANSION AREA: YES NO _ �0_�� �p iC' C.L E y ENGINEER TOWN WATER PRIVATE WELL BOARD OF HEALTH EXCAVATOR SKETCH: (Street hame, etc. ,dime.nsions of lot, exact location of test holes and percolation tests, locate wetlands in proximity to test holes ) 1 NOTES : A O.q KMONT tz a.4.0 'pe-r-c. STN 2-roe 0 - "Pe✓L �1 nl I'S rl�� S5, Pr QM r , IV k7_U N _ i I PERCOLATION RATE: TEST HOLE NO: ELEVATION: TEST HOLE NO: -0-Z ELEVATION: 2 ! �%. 2 � S}/l3soi� ' 3 A1.2 3 • - 4 4 . 7 �iN� ®y" 8 -ONO 8 9 - 7� bV/�N — 10 r 5 10 SA•vp ,11 11 12 12 13 13 14 14 15 15 16 16 - SUITABLE FOR .SUB-SURFACE .SEWAGE:'. ':LEACHING FIELD LEACHING PITS ✓ 'LEACHING TRENCHES '`UNSUITABLE FOR SUB-SURFACE SEWAGE. REASONS: r . NOTE: ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED ON PERC TEST APPLICATION ORIGINAL: COMPLETED IN ENTIRETY BY P . E , AND RETURNED TO BOARD OF HEALTH COPY: RETAINED BY APPLICANT s � a I 1\.` ' * 1 ` ! "R /o/ • ( _Ile TOP OF FAUN D,:TION CONCRETE COVER ., CONCRETE COVERS E-7R ''• ,f'tiN •� ,:�,r,-/n,,,,•rrr �c ' /o l= . :.CST iRJN IZ Mkx p// ' _ .ck 1 ,-_c OR St�U�E 4G �,. 12'n!-X _ - i PV.C. PIPE 4`SCHEDULE 40 PVC (ON-Y) \ -T , PITCH I/4P r• `— PIPE - MIN, LEACH i. ��L . J - r PITCH 1/4-PER F7 -�- '� Pt iC a�° n {--+�-•--rr-r+rs-iy+rr _� --* 'J T PR E7 24 ST r SEPTIC TANK INVERT DIS'r INVERT '` W jc'— P;T LA Z EG 1I V. INVERT-- EL.. . . . . . . . . 1 ®01C EL. �.� !. >_ ��, EL,:-� ?. t L �� GAL, I INVERT? INVERT � ' `✓W w c 3/4"T^ ' EL.. 7 ., t t.2 ! .P Lu STONE Ac " 4 0 � - -' D I A. sac.....rcr er, PROFILE OF E - , GRpUND WAT R TABLE ` TZZ SEWAGE DISPOSAL SYSTEM i �`-: �•' -�. ' � J � ``Y �, tw-:✓ � �GfF fr / l NO SCALE ' ! � •''.,fit � �, �,; ` � /�- �3 -� /? =r� _ � _ �vE SOIL LOG G _ WITNESSED BY : aZ ��y�� ` � DATE �.vs 2� s49S TIAIE. .is �a �•i • . 7E.5 /Go.-! . BOARD OF HEALTH t M f „ _ _ vE TEST HOLE 1 TEST HOLE 2 EDw Lc- i ► _ _ �' ` ( i ELEV. /.�5,04 ELEV. ./oC 70 '� —,r• ENGINEER t ! R , , t i �l.e �� ��, J-6 soif- � � az DESIGN DATA : + ► � � - ' 1 •4i• ,� S..rj_Sa.t- s t �o3.Zo NUMBER OF BEDROOMS . . . . . . . . . . . . . . . E TOTAL ESTIMATED FMC. LOW o . GALLDNS/DAY /� ' fox :�•--- P'r y4.,o f4 fQ,99 7o BOTTOM LEACHING AREA //3,/o SOFT. /PIT/&*,3C.RD, Jy SIDE LEACHING AREA l 1 '" ,z IfG'a/Li.✓� /BQ,�o . . SQ.F7./ PtTf3/2.7C.1,D, - / .. I SEyT7C "'E— // GARBAGE DISPOSAL . y . ..(50% AREA INCREASE)TOTAL LEACHING AREA �p'4.8 SC.FT K•9z_oo 'On. ez 9J. 70 �c r,..�.�S PERCOLATION RATE - MIN/INCH u LEACHING AREA PER PERCOLATION RATE #-R. SG.FT. C.R r � .. .WATER ENCOUNTERED NUMBER OF LEACHING PITS �'� Pik ✓�/i77/ t . . I APPROVED . .. 1 � .- � . . . . . . . . . . BOARD OF HEALT?i DATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I AGENT OR INSPECTOR R �,,; ► �` Z _ j gyp'" . ► ; - � �-✓ �� Qom` A ... ..�' -' .G.y�.9QwD . /`l�4sS • ; 1 e y r I /''�c,,.,,• _ Zr'�oS rE,C /� � ` PETITIONER 8 6 ti { ,//B i -014- - - Jo -77 !J Sr TE PC.�1�✓ �- ,�/vs T.9�3L�- cv�s�,,q � .a /Vh ss 1 / x t - !7 F ^v f w ` feeAI .ram i .. t/, �- =TG — �Z�'Y.G-nnJS ai4.�E'T. Ci.t rC .'...�i.� ':�E ✓' isEG:, i 'y'E.7...-;r' .^,►�.y a z +