HomeMy WebLinkAbout0031 RYDER LANE - Health 31 Ryder Lane
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Commonwealth of Massachusetts s 351" 0151.71 t
Title 5 Official Inspection Form
Subsurface Sewage Disposal.System Form -Not for Voluntary Assessments
`� _ �✓ 31 Ryder In (System 1 of 2 Main h )er em house) + '1ti 1 • 4 .y1 :f {• ' t•t. i•1 r{' '�Ja.
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Property Address
Dorothy Carpenter
Owner Owner's Name
information is
required for every C'w - Bee J - r+' MA 02637 8-2-18 <.2
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form. r•F�- r,f
A. General Information
1. Inspector: •. ...
• Shawn Mcelroyl' r ,i
Name of Inspector '
Upper Cape Septic Services
Company Name
P.O. Box 73 1
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S13971
Telephone Number License Number
B. Certification ,•„ ; ; � ;., �.
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true;accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000).The system: ' '' ' � • ',
® Passes •, r r, . �,�y 1 ❑ Conditionally Passes Fails,r
❑ Needs Further Evaktobn by the.Local Approving-Authority{
• � 8-2-18 _
I pector's Signature i r Date `
r
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 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.
1.. ****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17'
Commonwealth of Massachusetts
la l -, Title 5 official Inspection Form
f N Subsurface Sewage Disposal System Form Not for Voluntary Assessments
�8
31 Ryder In (System 1 of 2 Main house
Property Address
Dorothy Carpenter
Owner Owner's Name
information is Cummaguid MA 02637 8-2=18 '
required for every
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.) .
Inspection Summary:'Check A,B,C,D or E/always complete all'of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
System is in good working order with no sign of failure.
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.
o
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a-complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
�- Commonwealth of Massachusetts ;�a�r, ,F�•�, = • -+' �.r. r,'.`a• t,�` • , .'�'
XI f Title 5 Official Inspection Forte
(' N Subsurface Sewage Disposal System Forme-Not for Voluntary Assessments
Y r,V
31 Ryder In (System 1 of 2 Main house) r ''.} . • r y Fr Y,: .. --
Property Address
Dorothy Carpenter
Owner Owner's Name r
information is s.
required for every Cummaquid ' _ •..' 4 t MA 02637 8-2-18
page. City/Town _ , f State Zip Code Date of Inspection
B. Certification (cont.) #
❑ Pump Chamber pumps/alarms not operational.•System will pass with Board of Health approval if
pumps/alarms are repaired. `'
B) System Conditionally Passes (cont.): tit ;1 {„;w
❑ Observation of sewage backup or break out or'high static water level;in.the distribution box due
to broken or obstructed,pip'e(s) bird ue to a broken, settled'or uneven,distribution box. System will
pass inspection if(with approval of Board of Health):-
❑ broken'pipe(s) are'replaced` '' a r,` ❑ YY° ❑ `N ❑,'ND(Explain below):
❑ `{ obstruction is`removed '❑_Y' ❑;N",❑ ND,(Explain below):
❑ distribution box is leveled or replaced ❑l Y ❑ N '❑ ND (Explain below):
❑ 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 ❑ Y. ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑` ND (Explain below):
C) Further:Evaluation is Required by the Board of Health: ,;,_.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`
i 1. System will pass unless Board of,Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in'a manner which will protect public health,
safety and the environment: ;
.:
❑ Cesspool or privy is within 50 feet ofa surface water
❑ Cesspool or privy'is within'50 feet of a bordering vegetated wetland or a salt marsh
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
r r
Commonwealth of Massachusetts
:a p Title 5 Official Inspection Form
1.1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
31 Ryder In (System 1 of 2 Main house)
Property Address
Dorothy Carpenter
Owner Owner's Name
information is Cumma uid MA 02637 8-2-18
required for every q
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
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: ) . .T
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank'and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ 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 fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
3. Other:
. r -
D) System Failure Criteria Applicable to All Systems:
You must indicate ",Yes" or"No"to each of the following for all inspections:
Yes No
El ® Backup of sewage into facility or system component due to overloaded or
. clogged SAS or cesspool
❑ ® Discharge or ponding of'effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y day flow
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts ~. ,
f Title 5 Official Inspection Form .r
R' �'f;4 Subsurface Sewage Disposal System,Form -Not for Voluntary Assessments
-4,!„i' 31 Ryder In (System 1 of 2 Main house) :
Property Address k
Dorothy Carpenter
Owner Owner's Name
information is
required for every Cummaquid r`" MA 02637 8-2-18,
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.) 1 :'
Yes No
E] ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy_is within 100 feet of a surface water supply or
❑ ® tributary'to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® ' Any-portion'of a cesspool or privy is within 50 feet of a private water supply well.
❑' ®• ''' Any portion of a cesspool or'privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
- system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system,is acesspool serving a facility with a,design flow of 2000gpd-
10,000gpd: F r
❑ ® , The system fails. I have determined that one or more of the above failure
criteria exist'as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
a necessary to correct the failure.,.,
E) Large Systems: To be considered a large system the.system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either.'yes" or-"no"to each of the following, in addition to the
questions in'Section D. x'
Yes No
❑ ❑ the system is within 400 feet of dsurfaceldrinking 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
f `❑'� '❑- f the
— IWPA) or a mapped Zone ll of a public water supply well
If you have answered "yes"to any question in Section E the system'is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
911P.;
Title 5 Official Inspection Form
i t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
31 Ryder In (System 1 of 2 Main house)
Property Address
Dorothy Carpenter
Owner Owner's Name
information is Cumma uid MA 02637 8-2-18
required for every 4
page. City/Town State Zip Code Date of Inspection
C. Checklist -
Check if the following have been done. You must indicate "yes" or"no" as to each of the following:
Yes No ,
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system.components pumped out in the previous two weeks?
® ❑ Has the'system received normal flows in the previous two week period?
❑ , ® 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?
o
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance-of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on: '
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
.Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
f Title 5 Official Inspection Form
Subsurface Sewage Disposal System•Form -Not for Voluntary Assessments
31 Ryder In (System 1 of 2 Main house)
Property Address
Dorothy Carpenter _� >
Owner Owner's Name
information is Cumma uid MA 02637 8-2-18 .
required for every q
page.e. Cityfrown State Zip Code Date of Inspection
, .
D. System Information � : , •�, . . •,:. ,. _
Y •
Description:
Number of current residents: 1
Does residence have a garbage grinder?: ❑ Yes ® No
Is laundryseparate
on a s p rate sewage system? (Include laundry system inspection.
information in this report.)
• i ❑ Yes ® No
Laundrysystem inspected? ;t .It- ❑ Yes No
Y P ®�
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)): u
Detail:
Sump pump? 1, ❑ Yes ® No
Last date of occupancy: a - 8-2018Date
Commercial/Industrial Flow Conditions: ..• ;�
Type of Establishment:
Design flow(based,ont310 CMR 15.203): Gallons per day(gpd)'
Basis of:design.flow(seats/persons/sq:ft:, etc.): _
Grease trap present? r ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
" Commonwealth of Massachusetts
�al Title 5 Official Inspection Form
a, -I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
a s;!✓ 31 Ryder In (System 1 of 2 Main house)
Property Address
Dorothy Carpenter
Owner Owner's Name
information is required for every Cummaquid MA 02637 8-2-18
page. City/Town State Zip Code Date of inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: N/A
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy f
❑ 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) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe): ,
t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
�=1 f Title 5 Official l nspection Form
Subsurface Sewage Disposal System Form,-Not for Voluntary Assessments
31 Ryder In (System 1 of 2 Main house) ,1, -� •: r Ff ^. t _
Property Address
Dorothy Carpenter
Owner Owner's Name
information is required for every Cummaquid t" MA 02637 8-2-18 ct "
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of.information:
1996
Were sewage odors detected when arriving at the site? .❑ Yes ® No
Building Sewer(locate on site.plan):
24"
Depth below grade: - tf•, i-; feet
r ,
Material of construction: ,r ,, ; - , ,: , •w
-
f ® cast iron ®-40 PVC i ❑ other(explain):
- -q, #.
Distance from private water supply well or suction line:
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Good condition.
Septic Tank(locate on site plan):
Depth below grade: � :f 8 et
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene, ❑ other(explain)
If tank is metal, list age: years -
Is age confirmed by a Certificate of.Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gal
Sludge depth:
12"
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts jJ
a Title 5 Official Inspection Form
J�;l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
� '�u�_;;!✓ 31 Ryder In (System 1 of 2 Main house)
Property Address
Dorothy Carpenter
Owner Owner's Name
information is Cumma uid MA 02637 8-2-18
required for every q
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) ,
Septic Tank(cont.) j
Distance from top of sludge to bottom of outlet tee or baffle
20"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
6" -
Distance from bottom of scum to bottom of outlet tee or baffle
15"
How were dimensions determined? 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 is in good condition with baffles installed and no sign of leakage.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date L
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
.a=1 �r Title 5 official Inspection Foam 4 _ "
' � Subsurface Sewage Disposal System Form-Not forrVoluntary Assessments •;-it .•,S•
31 Ryder In (System 1 of 2 Main house)
Property Address t•r n `
Dorothy Carpenter • ,i, .' ;.r;==,;_
Owner Owner's Name _
information is r.
required for every Cummaquid MA 02637 8-2-18, r- + '
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) - ► :�►' R r ,;r .R ,�
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
� - .y f :-.r' .«1 �r - +'is,Yf4f _ ,..r t Y.:.'1 .,• :y rr�,"�� t'�
,{ •7 .�rS a wr. - .tfi a', «i. .�'« 'r' r ,. i.. j.1.,-J.
Tight or Holding Tank tank must be pumped at time of inspection) locate on site plan):
g 9 ( P P P ) ( P )
Depth below grade:
Material of construction: --
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons "
Design Flow:. , r. ;f.1,.,, 4,4;iz:-q
gallons pef day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: • Date
Comments (condition of alarm and float switches, etc.)
*Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins.doc-rev.6f16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
:a=1 Title 5 Official Inspection Fora `
f�
� 'i�'I Subsurface Sewage Disposal System Form Not for-Voluntary Assessments
31 Ryder In (System 1 of 2 Main house)
Property Address
Dorothy Carpenter
Owner Owner's Name
information is required for every Cummaquid MA 02637 8-2-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) .
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.):
Good condition with water at working level and no sign of back-up from field.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
as Title 5 Official Inspection Form p
.1� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
31 Ryder In (System 1 of 2 Main house) ;� : .i Caw,-
Property Address '' Y
Dorothy Carpenter • ,,, -;,,
Owner Owner's Name
information is umma uid ": ,i MA 02637 8-2-18'
required for every C 4 -
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1-1000 gal
® leaching chambers number:
3-cultec 330's
❑ leaching galleries number: • .
❑ leaching trenches - number;length:
❑ leaching fields number;dimensions:
❑ overflow cesspool rnumber: 1 i•. ►.,, +
❑ 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.): ,t,
Leach field in good working order with cultecs empty at inspection with no sign of failure.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration .
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17,
Commonwealth of Massachusetts ,
�=1 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for,Vo I untary'Assessments
%! 31 Ryder In (System 1 of 2 Main house)
Property Address
Dorothy Carpenter
Owner Owner's Name
information is
required for every Cummaguid MA 02637 8-2-18
page. City/Town ' State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locaWon 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.):
i •, I
t
t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
1 Commonwealth of Massachusetts .� ,� w: t • a ..
�aa Title 5 Official Inspection Form
�-, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
31 Ryder In (System 1 of 2 Main house) ctur , q.. • f ' rt:
Property Address ,
Dorothy Carpenter
Owner Owner's Name m;
information is
required for every Cummaguid MA 02637 8-2-18'
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) R 1
Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately ,ti
1
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t5ins.doc•rev.6/16. L: Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts -
:a=1 Title 5 Official Inspection :Form
i1l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
31 Ryder In (System 1 of 2 Main house)
Property Address
Dorothy Carpenter
Owner Owner's Name
information is required for every Cummaguid MA 02637 8-2-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
F• i /
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 12'+
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
® Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS data - explain:
You must describe how you established the high ground water elevation:
Original design plans show no groundwater at 12'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
f Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
31 Ryder In (System 1 of 2 Main house) `
Property Address
Dorothy Carpenter
Owner Owner's Name
information is Cumma uid MA 02637 8-2-18
required for every q
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
E Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
E System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
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Commonwealth of Massachusetts :�. ,• �.-. �
a p Title 5 Official Inspection Form . ,- ,
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hI Subsurface Sewage Disposal System Form,:Not for-Voluntary Assessments:[- r• . :,r•
31 Ryder Ln (System 2 of 2 Cottage) L �. L ,� r
Y Y 9
. !
Property Address .._Y -� •-t-, �.,
Dorothy Carpenter
Owner Owner's Name '10
information is QQ __ // MA . 02637. 8-2-18. r P,r,�.: - 4,
required for every (�lCr�/. '
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see.completeness checklist at the end of the form.
A. General Information
1. Inspector: 5
+ Shawn Mcelroy �` '- ,' ` t . ,' A.-O !•* , .t, a ; f -, .
Name of Inspector M
Upper Cape Septic Services {,� r,:.•;
Company Name
P.O. Box 73
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S13971
Telephone Number License Number
B. Certification .
I certify that I have personally inspected the,sewage disposal system at this address and'that the
information reported below is.true; accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the'proper functiomand maintenance of on site
sewage disposal systems. lam a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.600). The system:
Z,Passes., r.; ,, ❑, Conditionally Passes, ❑;(Fails
❑ Needs,Further.Ev io he Local Approving'Authority _
-.^ . 8-027.18
Ins or'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 has a design flow of
10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original should be sent to the system owner and copies sent to the
'buyer, if applicable, and the approving authority.'
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
l
t5ins.doc•rev.6/16 rs Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 f_
U4d✓_ I
Commonwealth of Massachusetts r
laa Title 5 Official Inspection Form
it Subsurface Sewage Disposal System Form Not for Voluntary Assessments
31 Ryder Ln (System 2 of 2 Cottage)
Property Address
Dorothy Carpenter
Owner Owner's Name
information is required for every Cummaguid MA 02637 8-2-18
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.) a
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
System is in good working order with no sign of failure.
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.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is'replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain,below):
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts F �1,•, s
as Title 5 Official' Inspection " Forn1 .
r•1 G-;
I Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .is', .*l
t� a�
31 Ryder Ln (System 2 of 2 Cottage)
Property Address •. .
Dorothy Carpenter
Owner Owner's Name
information is
required for every Cumma quid
• MA 02637 8-2-18„ '•. '
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.) -
❑ Pump Chamber pumps/alarms not operational. System.will pass with.Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.): ` - 3 -.► '
❑ 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)"
f
' ❑ `broken pipe(s) are replaced" 0 aY 'El"N' , ❑ ND (Explain below):
❑ obstruction is`removed n '`"' :Fly. ❑`{N ❑ 'ND'(Explain'below):
❑ distribution box is leveled or replaced ❑ "❑ N` `'❑ ND (Explain below):
• •r � 1.' i`r# .. ; Fin- r��#t: ff`'ri s1 Fa�'1••. firr+3";�s+•• ;1 1f
"r � Yak•.., +t:
❑ 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 - ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND-(Explain below):
C) Further Evaluation is Required by the Board of-Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment``• °
I'."System will pass unless Board of Healthy determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in'a manner which will protect public health,
' safety and the environment:
❑ Cesspool or'privy is within 50 feet of"a surface water
❑ ' Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins.doc rev.6/16• Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
,
. Commonwealth of Massachusetts r
:+ f Title 5 Official Inspection Form F
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
v�
u !q 31 Ryder Ln (System 2 of 2 Cottage)
Property Address
Dorothy Carpenter
Owner Owner's Name
information is required for every Cummaquid MA 02637 8-2-18
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ 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 fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or."No"to each of the following for all inspections:
Yes No
El ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or bonding 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 '/2 day flow
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
I
Commonwealth of Massachusetts :
:a=1 fop Title 5 Official Inspection Forhia
' 'i;.l Subsurface Sewage Disposal System Form =Not for Voluntary Assessments
31 Ryder Ln (System 2 of 2 Cottage)
Property Address +
Dorothy Carpenter
Owner Owner's Name
information is
required for every Cummaquid .'`i MA 02637
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.) R
Yes No
❑ ® 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.
Ej 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 1 of a public well.
El' ® Any portion'of'a cesspool or privy is within 50 feet of a private water supply well.
❑ ® �A:ny portion`of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal toror less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
- and chain of custody must be attached to this form.}
❑ ® The system`is a cesspool tserving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. (.have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure:
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd. ,
6 .
For large systems, you must indicate'either,`yes or"no"ito each of the following, in addition to the
questions in Section D.,t_.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking i uatersupply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
r , El 0 the system is located'in a nitrogen sensitive area (Interim Wellhead Protection
Area—rt IWPA) or a mapped Zone II of a public water supply well
at
If you have answered "yes"to any question in Section E'the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
h system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
• , Commonwealth of Massachusetts
f Title 5 Official. Inspection Form
�� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�.�p!✓ 31 Ryder Ln (System 2 of 2 Cottage)
Property Address
Dorothy Carpenter
Owner Owner's Name
information is Cumma uid MA 02637 8-2-18
required for every q
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or"no" as to each of the following:
Yes No '
❑ , ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ Z 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?
® E] 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?
® t ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® Was the facility owner(and occupants if different from owner) provided with
information on'the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® . ❑ Determined in the Feld (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information F
Residential Flow Conditions:
Number of bedrooms (design): 1 Number of bedrooms (actual): 1
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 110
t5ins.doc•rev.6/16 . Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts :r
R Title 5 Official . Inspection Fora
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments-
--- 31 Ryder Ln (System 2 of 2 Cottage)
Property Address
Dorothy Carpenter
Owner Owner's Name
information is
required for every Cummaquid r MA 02637 8-2-18
page. City/Town State Zip Code Date of Inspection
D. System Information ;-:
Description:
Number of current residents:
0 I
Does residence have a garbage grinder? '; ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection -' ❑ Yes ® No
information in this report.)
Laundry system inspected? �,rR,;. ,, ❑ Yes ® No
Seasonal use? ,_� t•� [ . t it C4 ,.. _ ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? "„ E - ,, •a ❑ Yes ® No
Last date of occupancy: , a 2018
Date
Commercial/Industrial Flow Conditions: •�. ►. t s _ `
Type of Establishment:
Design flow(based on 310 CMR-15.203): � +
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present?. + °L ,: + rt 3 + , r, • ;e.ff+, ❑ Yes ❑ No
Industrial waste holding tank present?;t t f ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? _ ❑ Yes ❑ No
Water meter readings, if available:
t5ins.doc-rev.6/16- Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
l_
I
Commonwealth of Massachusetts
aI t Title 5 Official Inspection Form
'
m
I.+ p
!, �� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
31 Ryder Ln (System 2 of 2 Cottage)
Property Address
Dorothy Carpenter
Owner Owner's Name
information is Cumma uid MA 02637 8-2-18
required for every q
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use:
Date
Other(describe below):
General Information
Pumping Records:
Source of information: N/A
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
` ❑ Other(describe):
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts f=_ � . , , •r,;
:r f Title 5 Official, Inspection form � {
A; bl Subsurface Sewage Disposal System Form =Not,for Voluntary Assessments
31 Ryder Ln (System 2 of 2 Cottage) r. ► f _ ,r c +, 1v r'
Property Address
Dorothy Carpenter
Owner Owner's Name
information is
required for every Cummaquid MA 02637 8-2=18
page. City/Town t+, State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
1988
Were sewage odors detected when arriving at the site? ,- a ,❑ Yes ® No
Building Sewer(locate on site plan):-,4
Depth below'grade: 18"
feet
r� •
Material of construction: -
:1.^,ice,
❑ cast iron ` ® 40•PVC "`r' ❑ other{(explainj:'' ` ' '`
r4. '
Distance from private'water supply well'or suction line- ` "' 'h
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Good condition.
Septic Tank(locate on site plan):
Depth below grade: '' 12"
feet '
Material of construction: ,w
® concrete ❑ metal ❑ fiberglass .�,Elpolyethylene ❑ other(explain)
If tank is metal, list age: years'
Is age confirmed by a Certificate of Compliance? (attach•a copy of certificate)- ,, ❑ Yes ❑ No
Dimensions:
1000 gal H-20
rr
Sludge depth: 12
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
,^i f Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
31 Ryder Ln (System 2 of 2 Cottage)
Property Address
Dorothy Carpenter
Owner Owner's Name
information is required for every Cummaquid MA 02637 8-2-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
20"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
16"
How were dimensions determined? 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 is in good condition with baffles installed and no sign of leakage.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
I
Commonwealth of Massachusetts
to Title 5 Official, Inspection Form
; I Subsurface Sewage Disposal System.form -Not for Voluntary Assessments:,,1,,. a
a/
31 Ryder Ln (System 2 of 2 Cottage) r;L ' -i ,, ,r,, •, .
Property Address `
Dorothy Carpenter
Owner Owner's Name ,
information is Cumma uid
required for every q -_ MA 02637 8-2-18 .
page. City/Town State Zip Code Date of Inspection
D. System Information(cont.) t►..•.'{ . .:; , f ,;— -j,
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
t1 it .a
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction: -
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: „
gallons
Design Flow: l if r."1"L t".
gallons per day
Alarm present: ❑ Yes - ❑ No
Alarm level: - Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
,a Title 5 Official Inspection Form
11-1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r,
31 Ryder Ln (System 2 of 2 Cottage)
Property Address
Dorothy Carpenter
Owner Owner's Name
information is required for every Cummaquid MA 02637 8-2-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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.):
Good condition with water at working level and no sign of back-up from field.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
i
Commonwealth of Massachusetts _ , Ir.f,i.,."
Title 5 Official Inspection Formixi
: ., F
11 Subsurface Sewage Disposal System•Form -Not for Voluntary Assessments.-, r'
s`
31 Ryder Ln (System 2 of 2 Cottage) ;• , : .,t E,� . , , _, r; �,
Property Address
Dorothy Carpenter
Owner Owner's Name
information is
required for every Cummaquid MA 02637
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) �, �; �: • , • • `
• Type. .. , ,,-, �. ;r. . ! •j _,:;. � ' � . .sr., ., - ..
.J
❑ leaching pits number:
® leaching chambers - - number: 2-flodiffusers
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number,-dimensions:
❑ overflow cesspool .,number: .. r, ► t
❑ 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.):
Flodiffuser field in good working order and empty at inspection with no sign of back-up.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
I
Indication of groundwater inflow ❑ Yes ❑ No
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
, Commonwealth of Massachusetts
:a=1 Title 5 Official Inspection Form
Subsurface Sewage'Disposal System Form -Not for Voluntary Assessments -
31 Ryder Ln (System 2 of 2 Cottage)
Property Address
Dorothy Carpenter
Owner Owner's Name
information is
mma Cu uid MA 02637 8-2-18
required for every a •
City/Town State ZI Code Date of Inspection
page. P p
D. System Information (cont.)
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.):
1
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts *Y,r ,► � '
Title 5 Official Inspection Form
il-1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,!✓ 31 Ryder Ln (System 2 of 2 Cottage)
t J"
Property Address
Dorothy Carpenter
Owner Owner's Name
information is Cumma uid MA 02637 8-2-18
required for every 4
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
[
NL
All
117
} �y
- .•
d
-. 3
I
. .........
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 11
, Commonwealth of Massachusetts r
:asl Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
31 Ryder Ln (System 2 of 2 Cottage)
Property Address
Dorothy Carpenter "
Owner Owner's Name
information is required for every Cummaguid MA 02637 8-2-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) 3
Site'Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 1 t+
fee t
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
® Checked with local excavators, installers- (attach documentation)
® Accessed USGS database- explain:
You must describe how you established the high ground water elevation:
USGS and town maps show groundwater at greater than 12'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc•rev.6/16 Title 5 Official Inspeclion Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
�a=1 Title 5 Official Inspection Form
f,.
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
{!% 31 Ryder Ln (System 2 of 2 Cottage) _
Property Address
Dorothy Carpenter
Owner Owner's Name
information is required for every Cummaguid MA 02637 8-2-18
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
I
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
sx/ez'T / eF 3 S,4Eb7s
LOCATION (Cu
SCALE . . / �a DATE . . . . .
PLAN REFERENCE
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BARN THELE T01,04 CLERK
• $ Barnstable Old Kings Highway Historic District C® nittee
„ 200 Main Street, Hyannis,MA 02601,TEL: 508-862-4787 Fax 508-862-4784
N
1639.
Patr�'
APPLICATION CERTIFICATE OF APPROPRIATENESS
Application is hereby made, with four(4)complete sets;for the issuance of a Certificate of Appropriateness under Section 6 of Chapter
470,Acts and Resolves of Massachusetts, 1973,for proposed work as described below and on plans,drawings,or photographs
accompanying this application for:
Check all categories that apply;
1. Building construction: ❑ New ❑ Addition ❑'Alteration
2. Type of Building: ❑ House ❑ Garage/barn ❑ Shed ❑ Commercial 0Other jam Oft° .
3. Exterior Painting roof ❑ new.roof ❑ color/material change, of trim, siding, window,door
4. Sign : ❑ New Sign ❑ Existing Sign ❑ Repainting Existing Sign
5. Structure: ❑ Fence ❑ Wall ❑ Flagpole ❑ Retaining wall ❑ Tennis court ❑ Other
6. Pool ❑ Swimming ❑ Other man-made pool ❑ Solar panels ❑ .Other
Type or Print Legibly: Date 13
I It
:VOTE AU applications must be signed by the current owner
Owner(print): R, _g�d70tYW 0-0 QZ_ T QxA-V-Q(Z- Telephone.#: S lqvi
Address of Proposed Work: ,, 35'
P� �.�. `i��2.12. �..�_ Viilarie Map Lot
Mailing Address(if different) 'PE7 '31
Owner's Signature
Description of Proposed Work: Give parti tars of work to be done: Qe4etc 2 e _�i Q %IA�MaM
_ 19f .� �ula �e _ �Yt�S1S �Q
— C2 s Cep _
Agent or Contractor(print): Telephone#:
Address:
Contractor/Agent' signature: _
For committee usp only. This Certificate is here APPROW /'v v
Date Members signatures
Jla1P
GRow
A ogtable
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a
B a
t v
w
i 1d YVQ Htt
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(4oarrds mud Canullbsialavold Kings,Higlnrrtti•\U ff it pplit•otion.+4Ufift DRAFT 20I f(:ert Approprieurness DRAT?dor
/ ! '
COMMON WEALTY. OF IA.SSAf✓x3�,rSETTS
'ExECUTrvE, OFFICE OF ENVIRONTMENTAL AFFrAiRS
'DEPARTMENT OF ENVIRONMENTAL PROTECTION
REMEIVED
n
FEB Y5200 .
5
TOWN OF BARNSTABLE
TITLE 5 WEALTH DEFT.
OFFICIAL INSPECCTION FOR,'VI—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM 3 S 1
PART A --
CERTIFICATION "ARCELLOT
O 3rj
Property Address 1-,av,,,.2
Owner's Name: �-
Owner's Address Lo.vie
M t1 .0"37 t' F-1
Date of Inspection: &
I O QU ;
o1
Name of Inspector:(please print) i +t Le-
Company Name: a (lc.
en sc.�co yls - ��
Mailing Address: 40,Rnt AA41
q
Telephone Number: r"
j Vyl
CERTIFICATIONSTATEMENT
1 certify that 1 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_
x Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails S,
Inspector's Signature: Date: c3
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form =6/15/2000 page I
s ,
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE INSPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
�01
Owner.
Date of Inspection: O
Inspection Summary: Cl eck A B,C,D or L/ALWAYS complete all of Section D
A. System Passes:
k I have-not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally'Passes:
One or more system components as described in the"Conditio ass"section need to be replaced or
repaired.The system,upon-completion of the replacement or repair, oved by the Board of Health,will.pass.
Answer yes,no or not detertined(Y,N,ND)in the for following statements.If"not determined"please
explain.
The septic tank is metal and over 20 years old* r the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or a on or tank failure is imminent.System will pass inspection if the
existing tank is replaced with a complying as approved by the Board of Health.
;A metal septic tank will pass inspection if it' structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 y Id is available.
ND explain:
Observation of sewage ba or break out or High stag water level in the distribution box due to broken or
obstructed pipe(s)or due to'a br en,settled or uneven distribution box.System will pass inspection if(with
approval of Board of Health):
broken pipes)ae.tq%twed
obstrueticm,isremoved
di=1utiw box is kwledi or replaced
ND explain:
The sy required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass in3peCtio (with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
I� 2
Page of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
v 1
Owner:
Date of inspection: pti
C. Further Evaluation is`Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to etermine if the system
is failing to protect public tealtl,safety or the environment.
I. System will pass unless Board of Health determines in accordance wit 10 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public hen ,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 vegetate etland or a salt marsh
2. Svstem will fail unless the Board of Health(a Public Water Supplier,if any)determines that the
system is functioning in a manner that protects a public health,safety and environment:
_ The system has`a septic tank and soil sorption system(SAS)and the SAS is within 100 feet of a
surface water supply;or tributary to a e water supply.
____ The system has a septic tank d SAS and the SAS is within a Zone i of a public water supply.
The system has;a septic and SAS and the SAS is within 50 feet of a private water supply well.
_ The system hasa sop' tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply we] s.Method used to determine distance
"This system passe f the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatil organic compounds indicates that the well is free from pollution from that facility and
the presence of monia%nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other-
failure criteria a triggerred.A copy of the analysis must be attached to this form.
3. Othe .
3
Page 4 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS -
SUBSURFACE SERFAGE DffiPOSJ4 SYSTEM INSPECTION FORM
PART.A
CERTIFICATION(continued)
Property Address: QC"
Owner: tti
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge of ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS orcesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
1 cesspool
Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow
Required pumpixlg more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
_ Any portion.of the SAS,cesspool or privy is below high ground water elevation.
Any portion.�of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
Any portion.of aa.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 acesspool 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,
performedat aDEP certified laboratory;far worm bacteria and volatile organic.comptmnds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is egaatto or less than 5 ppm,provided that no other failure criteria
are triggered.A ropy of the analysis must be attached to this form.]
(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system mast s ea facility with a design now of 10,000 gpd to 15,M
gpd.
You must indicate either"yes"or"no"to each the following
(The following criteria apply to large cyst addition to the criteria above)
yes no
_ the system is within 400 t of a surface drinlang water supply
the system is within feet of a tributary to a surface drinking water supply
_ — the system is 1; in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a he.water supply well
If you have answ "yes"to any question in Section E the system is considered a significant threat,or answered
`yes"in Sectia above the large system has failed.The owner or operator of any large system considered a_
significant under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.Th system owner should contact the appropriate regional 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:
Owner:
Date of Inspection• tS cff
Check if the following have been done.You must indicate`yes"or`�io"as to each of the following:
Yes No
_ Pumping information was provided by the owner,occupant,or Board of Health
Were any of the system components pumped out in the previous two weeks':
�[ Has the system received normal flows in the previous two week period?
Have large volumes of water been introduced to the system recently or as part of this inspection?
Were as built plans of the system obtained and examined?(if they were not available note as NIA)
i Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
_ Were all system components,excluding the SAS,located on site?
_ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner)provided with information on the proper '
4 atenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on,
Yes no
— Existing information.For example,a plan at the Board of Health.
_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 C1M R 15.302(3)(b)J
5
Page 6 of 11
OFFICIAL INSPICTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
c2(
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual): 3
DESIGN flow based on 3I0 CMR 15.203 (for example: 110 gpd x#of bedrooms):
Number of current residents:
Does residence have a garbage grinder(yes or no): AZ
Is laundry on a separate sewage system(yes or no): , " f if yes separate inspection required]
Laundry system inspected(yes or no): A;00
Seasonal use:(yes or no)
Water meter readings,if available(last 2 years usage(gpd)): '
Sump pump(yes or no):
Last date of occupancy:
COMMERCIAL/INDL3STRIAL
Type of establishment:
Design flow(based on 310 CMR 15.20 0pd
Basis of design flow(sea.. persons/ etc.):
Grease trap present(yes or no) _
Industrial waste holding b present(yes or no):_
Non-sanitary waste di ed to the Title 5 system(yes or no):_
Water meter reading ,if available:
Last date of occ cy/use:
OTHER escribe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no):LUU
If yes,volume pumped: gallons—How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
_Septic tank,distribution box,soil absorption system ,
_Single cesspool
Overflow cesspool
Privy
Shared system(yes or na)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)..
_Tight tank _Attach a copy of the DEP approval
_Other(describe):
Approximate age of all cbmponents,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):&v
6
Page 7 of l i
OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE�;SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address*
Owner: Aa
Date of Inspection: O
BUILDING SEWER(locate off.site plan) .
it
Depth below grade: 36
Materials of construction: 1(c _ast iron 40 PVC_other(explain):
Distance from private water_supply well or suction line:
Comments(on condition of jointi,venting,evidence of leakage,etc.):
SEPTIC TANK:_(locate on,:site plan)
Depth below grade:
Material of construction: concrete metal_fi ass polyethylene
_other(expiain)
If tank is metal list age: Is age confumed b Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions:
Sludge depth:
Distance from top of sludge to bo of outlet tee or baffle:
Scum thickness:
Distance from top of scum to p of outlet tee or baffle:
Distance from bottom of s t bottom of outlet tee or baffle:
How were dimensions ermined:
Comments(on pum " g recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to out]e vent,evidence of leakage,etc.):
GREASE TRAP:_(locate onsite plan)
Depth below grade:_
Material of construction:_concrete metal_fiberglass,polyethylene,other
(explain):
Dimensions:
Scum thickness:
Distance from top of sc o top.of outlet tee or baffle:
Distance from bottom scum to bottom of outlet tee or baffle:
Date of last pumpm ,_
Comments(on p ping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to o et invert,evidence of leakage,etc.):
7
Page 8 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: `c. (— E-
Owner:
Date of Inspection: O
TIGHT or HOLDING:TANK: (tank must pumped at time of inspecrion)(Iocate on site plan)
Depth below grade:
Material of:construction: concrete metal fiberglass_polyethylene other(expiain):
Dimensions:
Capacity: Ions
Design Flow: one/day
Alarm present(yes or no)• `
Alarm level: arm in working order(yes or no):
Date of last pumpin
Comments(co di ' n of slam and float switches,etc.):
DISTRIBUTION BOX: (' resent must be opened)(locate on site plan)
Depth of liquid level above `:utlet invert.
Comments(note if bFx�
` e' I and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out o etc.):
PUMP CHAMBER: ate on site plan}
Pumps in working order es or no}:.
Alarms in working or i(yes or no):
Comments(note co 'tion of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
VYI
Owner-
Date of Inspection: ll0�a�/
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why;
Type
leaching pits,number .
leaching chambers,number_
leaching galleries,number.
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,numbed t .
innovative/alternativesystem Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
s t�Tb -
CESSPOOLS: (cesspool roust be pumped as part of inspection)(locate on site plan)
Number and configuration::
Depth—top of liquid to inlet invert:
Depth of solids layer. "
Depth of scum layer—L it
Dimensions of cesspool:
Materials of construction-dot.�W e,�l IGkcx c—
Indication of groundwater inflow(yes or no):j-N)p
Commen (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 ,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 3
_ J
Owner:
Date of Inspection-IRL
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.
Page 1 I of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: .3
Owner:
Date of Inspection:_ 4 to
SITE E
Slope
Surface water 00
Check cellar ve$
Shallow wells V 3 a
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 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 u established the high ound water clevatio
P I
11
2so(VIP
CO1VIIvIOIvTWEALTH OF I$ASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
RME1
v DEC 1.5 2004 =-
MlticH �UJ� TOWN OF BARNSTABLE
TITLE 5 HEALTH DEPT,
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL, SYSTEM FORM
PART A
s� CERTIFICATIONfjA
a �5
Property Address: 3 1, v�.Q O
Owner's Name: JOT
Owner's Address:
V �
Date of Inspection: 1 0
Name of Inspector:(please print) ` I Q. l
Company Name: a e,,;Zw
Mailing Address: d t
nrs s //7,4' j ..
Telephone Number:
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:
Y Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: � Date: 11
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
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 flow the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page I
a
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE IMSPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner.
Date of Inspection: D
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
I have-not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"secti eed to be replaced or
repaired-The system,upon completion of the replacement or repair,as approved the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the folio g statements.If"not determined"please
explain.
The septic tank is metal and over 20 years old*or septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfil=10 tank failure is imminent.System will pass inspection if the
existing tank is replaced with a complying septic as approved by the Board of Health
*A metal septic tank will pass inspection if it is cturally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years o is available.
ND explain:
Observation of sewage b p or break am or ingh static water level in the distribution box due to broken or
obstructed pipe(s)or due to a oken,settled or uneven distribution box.System will pass inspection if(with
approval of Board of Heal : "
broken pipes)amenplaced
obstruc tin fiT moved
distribution box is iewled or replaced
ND explain:
system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass' on if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2 ;
Page 3 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 24otel '�;kA
Owner
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 det ine 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 3 CMR 15.303(l)(b)that the
system is not functioning in a manner which will protect public health afety 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 Hand or a salt marsh
2. System will fail unless the Board of Health(and blic Water Supplier,if any)determines that the
system is functioning in a manner that protects t public health,safety and environment:
_ The system has a septic tank and soil sorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a s e water supply.
_ The system has a septic tank d SAS and the SAS is within a Zone 1 of a public water supply_
The system has a septic and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a se 'c tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply 1**.Method used to determine distance
**This system p es if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and vo the organic compounds indicates that the well is free from pollution from that facility and
the presence f ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure crit 'a are triggered.A copy of the analysis must be attached to this form.
3. her:
• 3
Page 4 of l l
OFFICIAL INSPECTION FORK —NOT FOR VOLUNTARY ASSESSMENTS _
SUBSURFACE SEWAGE Dj6rCk&4LL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: Jloefcfe4 Low
y� t
Owner: /�!/ .Ad a"'
Date of Inspection: CLMgLo9'
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
A' Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
f Liquid depth in cesspool is less than 5"below invert or available volume is less than'/z day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pq*s).Number
of times pumped
Any portion of the SAS,cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis.{This system passes if the well water.analysis,
performed at a DEP certified laboratory;for coliferm bacteria and volatile organic_compowids
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve cility with a design flow of 10,000 gpd to 15,000
l'd• { ..
You must indicate either"yes"or"no"to each o following
(The following criteria apply to large syst addition to the criteria above)
yes no
_ — the system is within 4 eet of a surface drinking water supply
_ the system is 200 feet of a tributary to a surface drinking water supply
the system' ocated in a nitrogen sensitive area(Interim Wellhead Protection Area IWPA)or a mapped
Zone II o public water supply well
If you have ans erect"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in n D above the large system has failed.The owner or operator of any large system considered a
significant eat under Section E or famed under Section D shall upgrade the system in accordance with 310 CMR
15.304. system owner should contact the appropriate regional office of the Department.
4
Page 5of11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: f�4ofCr nR
or
Owner: f
Date of Inspection: (1/oZa/Oct
Check if the following have been done.You trust indicate`yes"or"no"as to each of the following:
Yes No
Pumping information was provided by the owner,occupant,or Board of Health
1� Were any of the system components pumped out in the previous two weeks ?
Has the system received normal flows in the previous two week period?
Have large volumes of water been introduced to the system recently or as part of this inspection?
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
_ Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
X — 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?
0( _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
— Existing information_For example,a plan at the Board of Health.
_ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance
is unacceptable)[310 CUR 15.302(3)(b)],
5
Page 6 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: S/
Owner:
Date of Inspection: 8
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): c3
DESIGN flow based on 310 CMR 15.203 (for example. 110 gpd x#of bedrooms):
Number of current residents: 42
Does residence have a garbage grinder(yes or no): �tAD
Is laundry on a separate sewage system(yes or no): .W {if yes separate inspection required)
Laundry system inspected(yes or no):
Seasonal use:(yes or no): A)O
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no):AXb
Last date of occupancy: Cy_
COMMERCIAIANDUSTRIAL
Type of establishment:
Design flow/SRn 310 CMR 15.2 trpd
Basis of des (seats/peYso gft,etc.):
Grease trap yes or no):
Industrial wing resent(yes or no):Non-sanitarisc ged to the Title 5 system(yes or no):Water meters,° available:East date of y/use:OTHER(d
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no): l�70
If yes,volume pumped:_gallons—How was quantity pumped determined?
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/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy of the DEP approval
Other(describe):
Approximate age of all eomponen date installed(if known)and source of information:
1o�/
Were sewage odors detected when arriving at the site(yes or no):/t.
6
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
nSYSTEM INFORMATION(continued)
Property Address: 31 2 dCQ/1
v t
Owner: Q
Date of Inspection: 111ai7ow
BUILDING SEWER(locate on site plan)
Depth below grade:_
Materials of construction:_cast iron K 40 PVC_other(explain):
Distance from private water supply well or suction tine:
Comments ton condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: A (locate on site plan)
Depth below grade:_tj o
Material of construction: K 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: lDe�b _
Sludge depth: oZ n
Distance from top of sludge to bottom of outlet tee or baffle:(D
Scum thickness: c?
Distance from top of scum to top of outlet tee or baffle: W LD "
Distance from bottom of scum to bottom of outlet tee gr baffle: /3 7
How were dimensions determined: re4xwezf
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid Ievels
as relatedsp outlet invert,evidence of leakage,etc.):
yet/c -a 7� , i 7�c I, /a.c C a
GREASE TRAP:_(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal erglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top o utlet tee or baffle:
Distance from bottom of scum ttom of outlet tee or baffle:
Date of last pumping:
Comments{on.pumping commendations,inlet and outlet tea or baffle condition,structural integrity,liquid levels
as related to outlet in ,evidence of leakage,etc.):
7
Page 8 of I i
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORIM
PART C
SYSTEM INFORMATION(continued)
Property Address: P A4 ot
Owner:
Rate of Inspection: IL t pieb a
TIGHT or HOLDING TANK: (tank must be pumped at ' of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal berglass polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallo day
Alarm present(yes or no):
Alarm level: Alarm in orking order(yes or no).
Date of last pumping:
Comments(condition of and float switches,etc.):
DISTRIBUTION BOX:Y(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: tow
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.): �/ ,,/
`/Zte l&x uza5 1p ue(c1c u.ct' -ic V w�71�t n a -5 4g A rr GC�k,oUfi?,
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no -
Alarms in working order(yes o):
Comments(note conditio pump chamber,condition of pumps and appurtenances,etc.):
r
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSUP&ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: "A
Owner: n
Date of Inspection: ( Q�
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
OC leaching pits,number.
leaching chambers,number:
,per 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.): "
CESSPOOLS: (cesspool must be pumped as part o inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater irgow(yes or no):
Comments(note conditi 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 conditio f soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: J44
Owner. o
Date of Inspection: 8 o
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 eaters the building-
t
l ��
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1?, k0 Awe
v
Owner: A
Date of Inspection: J( JJ ce IO
SITE EXAM
Slope Y'*
Surface water 00
Check cellar
Shallow wells m)O
Estimated depth to ground water l a- feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with Iocal excavators,installers-(attach documentation) '
Accessed USGS database-explain:
You must describe how ypu epablished the high ground water eie tion:
! a
I1 .
COMMONWEALTH OF MASSACHUSETTS
ExECUVE OFFICE OF ENVIRON"1VltEN�PA3.
TI AF F AIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
C "ARCEI: 0 3 5
LOT C<�lam►`t
TITL 5
OFFICIAL INSPECTION FORM—NOT F UNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:
/19 i ,..,
Owner's Name- alt
Owner's Address: a f.P
7 :
Date of Inspection:
'E
Name of Inspector: ieeaa��e print)
Clef
Company Name, rK -
Mailing Address:
!rt _yo�6Y�
Telephone Number: .SaB 3BS•?6 OS 4a r^
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 aad 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
Tails
T
Inspector's Signature: i Date: �_6L�- -
The system inspector that[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
se and copies sent to the buyer,if applicable,and the approving
DEP.The original should be sent to the-system ow
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This insertion does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
4
Page 2 of i l
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS -
SUBSURFACE SEWAGE INSPOSAL`SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 3( --
Owner: i w
Date of Inspection• o'S
Inspection Summary: Check A,B,CM or E!ALWAYS complete an of Section D.
A.. System Passes:
I have-not found any information which indicates that airy of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments-
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"s on need to be replaced or
repaired The system,upon completion of�e replacement or repair,as approv by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)
in the for the follo ' g statements.If"not determined"please
explain-
The septic tank is metal and over 20 years old*or the tic tank(whether metal or n� �1l if the
unsound,exhibits substantial-infiltration or exfiltradion or failure is u nrament.System p inspection
existing tank is replaced with a complying septic tarok ved by the Board of Health.
not lea
*A metal septic tank will pass inspection if it is stru y sound, king and if a Certificate of Compliance
indicating that the tank is less than 20 years old' vailable.
NDexplain:
Observation of sewage backu r break out or High sta=water level in the distribution box due to broken or
obstructed pipe(s)or due to-a brok settled at uneven distr>tion box.System will>pass inspection if(with
apprwW of Board of Health):
broken pipe(s)area
obsowaimisremoved
distrjt�tion boot is kwJed m'replaced
ND explain:
The :required pursing more than 4 times a year due to broken or obstructed pipe(s).The system will
pass in if(with approval of thn Board of Health):
broken pipe(s)are replaced
obstruction is removed.
ND explain:
2
Page 3,of l l ,
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: o
Owner:
Date of inspection: 1'(JA atd s-
C. Further Evaluation is Required by the Board of Health: .
Conditions exist which require further evaluation by the Board of Health in order to termine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance wit 10 CMR 15.303(l)(b)that the
system is not functioning in a manner which will protect public h ,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 vegeta wetland or a salt marsh
Z. System will fail unless the Board of Health nd Public Water Supplier,if any)determines that the
system is functioning in a manner that prot the public health,safety and environment:
_ The system has a septic tank and absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a ace water supply.
The system has a septic and SAS and the SAS is within a Zone 1 of a public water supply.
— The system has a septi and SAS and the SAS is within 50 feet of a private water supply well.
The system has a tic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply ells#.Method used to determine distance
**This system p es if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and vo rile organic compounds indicates that the well is free from pollution from that facility and
the presence ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure crite a are triggered.A copy of the analysis must be attached to this form.
3. O er:
3
Page 4 of l l
OFFICIAL.INSPECTION FORM--NO'T FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISpOSAL SySTEM INSPECTION FORM
PART..A
CERTIFICATION(continued)
Property Address:—SA _
Owner:
Date of Inspection: �Q[OY
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for&11 inspections:
Yes No
f 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
_[A Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow
=� Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Plumber
of times pumped - "
Any portion of the SAS,cesspool or privy is below high ground water elevation:
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
4 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.
e� 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 d the well water.analysis,
performed at a DEP certified laboratory,for CoNform bacteria and volatile organic compaw3ds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equatto or less than 5.ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be starched to this form.)
/1I D (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,threfore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems: to 15,Q00
To be considered a large system the system mast serve a cility with a design flow of 10,000 gpd
gpod Yu must indicate either"yes"or 11no"to each of llowing:
(The following criteria apply to large systems' on to the criteria above)
yes no = "
_ — the system is within 400 f of a surface drinking water supply
— — the system is 00 feet of a tributary to a surface drinking water supply
_ — the system is d in a nitrogen sensitive area(Interim`Wellhead Protection Area—IWPA)or a mapped
Zone II of ublic water supply well
If you have ans "yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Secti D above the large system has failed.The owner or operator of any large system considered a
significant eat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304., system owner should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY SS NTS
SUBSURFACE SERFAGE DISPOSAL SYSTEM INSPECTION
PART B
CHECKLIST
Property Address: 3
c
Owner: o '
Date of Inspection:
Check if the following have been done You must indicate"yes"or-no"as to each of the following_
Yes No
_ pumping information was provided by the owner,occupant,or Board of Health
_ Were any of the system components pumped out in the previous two weeks' r
X _ 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 pare of this inspection?
Were as built plans of the system obtained and examined?(if they were not available note as NIA)
Was the facility or dwelling inspected for signs of sewage back up?
jr Was the site inspected for signs of break out?
0 — Were all system components,excluding the SAS,located on site?
n and the interior of the tank inspected for the condition
Were the septic tank manholes uncovered,opened
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 frow.owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
K _ Existing information.For example,a plan at the Board of Health.
X Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unac-
ceptable)j310 CMR 15302(3)(b))
5
Page 6 of I I.
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 3[ ve er
Owner /�i�t��.a(fie ►. _
Date of Inspection: li 1 l�
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): *L
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): �D
Number of current residents: O
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): AD if yes separate inspection required]
Laundry system inspected(yes or no): AM
Seasonal use:(yes or no): Ma;
Water meter readings,if available(last 2 years usage(gpd))-
Sump pump(yes or no): A)O
Last date of occupancy: 4770 —
y
COMMERCIAJANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): °pd '
Basis of design flow(seats/persons/ c.):
Grease trap present(yes ur no):
Industrial waste holding tank nt(yes or no):—
Non-sanitary waste disch ed to the Title 5 system(yes or no):_
Water meter readings, available:
Last date of occup y/use:
OTHER(d cnbe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no):
If yes,volume pumped:_gallons—How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
�( Septic tank,distribution box,soil absorption system
_Single cesspool
Overflow cesspool
Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank _Attach a copy of the DEP approval
Other(describe):
Approximate age of all omponen date' led(if known)and source of information:
31 ri 0$ 09
Were sewage odors detected when arriving at the site(yes or no): IVO
6
Page 7 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 31 424 A�� '
Owner: 4
Date of Inspectioa: it
BUILDING SEWER(locate on site plan) .
Depth below grade: off-Y
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 K(locate on site plan)
Depth below grade:_
Material of construction: .(concrete_meta! 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: lyOd�W r
Sludge depth 4
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: I it
Distance from top of scum to top of outlet tee or baffle: 7 _
Distance from bottom of scum to bottom of outlet tee baffle:�__
How were dimensions determined: �+Gc scx:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related outlet invert,evidence of leakag et�� � .
t
GREASE TRAP:_(locate on site plan)
Depth below grade:_
Material of construction: concrete metal glass=polyethylene other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of tlet tee or baffle:
Distance from bottom of scum t ttom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping r mmendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet inve ,evidence of leakage,etc.):
7
f
Page 8ofll
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE(DISPOSAL.SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address• 31
Owner:
Date of inspection: It jftjaV'
TIGHT or HOLDING TANK: (tank must be pumped at tim inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal class---polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: day
Alarm present(yes or no):
Alarm level: Alarm' oridng order(yes or no):
Date of last pumping:
Comments(condition o and float switches,etc.):
DISTRIBUTION BOX: (if present must be opened)(locate on site plan) '
Depth of liquid level above outlet invert: j�WK 7
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.): /
� wt o S ra a .r c�5':r�r.
PUMP CHAMBER: (locate on site pl
Pumps in working order(yes or n
Alarms in working order(yes no
Comments(note conditi of pump chamber,condition of pumps and appurtenances;etc.):
. 8 _
Page 9 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEW' AGE ]DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address• A- -
Cv `
Owner:
Date of Inspection: Z114P$? D
SOIL ABSORPTION SYSTEM(SAS): 6C (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:_
leaching chambers,number. o7
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.):
rs r S%JrrovKa� 1
� •
CESSPOOLS: (cesspool must be pumped asp i ns pection)(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 groundw r inflow(yes or no):
Comments(note co ttion 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 ondition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
t
9
Page 10 of I 1
OFFICIAL INSPECTION FOR11+lE—'NOT FOR VOLUNTARY INSPECTION FORM
ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM
PART C
SYSTEM INFORMATION(continued)
Property Address: �t�' v✓
Owner: /• o
Date of Inspection- g
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at bast two permanent reference landmarks or
benchmarks_Locate all wells within 100 feet.Locate where public water supply enters the building.
t
r
I
r _
Page 11,of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 3► 2 .
Owner:
Date of Inspection: 1 t R eq
SITE EXAM M.
Slope
Surface water sA-"
Check cellar k'-5
Shallow wells OW
Estimated depth to ground water /at feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
�! Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe h w you established the high gro rid water ievation:
11 .
TOWN OF BARNSTABLE
r' ,3 - -a0
1- 4��N 1- 4SEWAGE # �f
VILLAGE_C U M Al p U f66 ASSESSOR'S MAP & LOT "d 3-
INSTALLER'S NAME&PHONE NO. p /Vl A C 0/11 �3e/1 f--So//l1 s=3�3�
SEPTIC TANK CAPACITY /- O ®D t /
LEACHING FACILITY: (type) s ec#A R G e f (size) 3 30
/V'e W
NO. OF BEDROOMS
BUILDER OR OWNER__
PERMIT DATE: A0 �!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 leachii facility) Feet
Furnished by
sr
i
r 1 �•
e
-s az'o
No. Fee 5 0.0 0
THE COMMONWEALTH OF MASSACHUSETTS _
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
01pprication for Migaoal *p5tem Congtruction Permit
Application is hereby made for a Permit to Construct( )or RepairXX)D an On-site Sewage Disposal System at:
Location Address or Lot No.31 Ryder Lane Owner's Name,Address and Tel.No. —
3039
Cummaqquid,Mass. 02637 Bruce Lovejoy 31 Ryder Lane
Assessor's Map/Parcel C umm a qui d,Mass. 02637
Installer's Name,Address,and Tel.N,-. 5-8-7 7 5-3 3 3 8 Designer's Name,Address and Tel.No. 5 0 8—7 7 5—3 3 3 8
�.P.Macomber & Som: Inc.Box 66 J.P.Macomber & Son Inc.
enterville,Mass. 0263.2 Box 66 Centerville,Mass . 02632
Type of Building:
Dwelling XXXNo.of Bedrooms 3 Garbage Grinder(NO)
Other Type of Building RES No.of Persons 2 Showers( ) Cafeteria( )
Other Fixtures
Design Flow 3 3 Q gallons per day. Calculated daily flow 3�=1 1 9 gallons.
Plan Date 1 15 9 Number of sheets Revision Date
Title
Description of Soil Loamy, sand to clay to fine sand
Nature of Repairs or Alterations(Answer when applicable) Adding 3—3 3 n R P a lh a r agars to an existing
1000 gallon tank and leach pit. Distribution box will aiso 'hA added
Date last inspected: 1 0/1 5/9 6
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance?has been iss d b s oard of Health.
Signed Date 10/15/9 6
Application Approved by Date xe /erl
Application Disapproved for the following reasons
Permit No. � % Date Issued
?' p ,
it
$ 50. 00
4 ,
Fee
f THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC`HEAL�TH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
ZIppYicatton for Migpogar bpgtem Congtruction Permit
Application is hereby made/for a Permit to Construct( )or Repair'
(X)o an On-site Sewage Disposal System at:
Location Address or Lot No.31 Ryder Lane Owner's Name,Address and Tel.No. 62-3
039
Cummaquid,Mass . 02637 Bruce Lovejoy 31 Ryder Lane
Assessor's ap/Parcel Cummagizid,Mass. 02637
Installer's Name,Address,and Tel.No. 5-5-775-3338 Designer's Name,Address and Tel.No. 508-775-3338
.P.Macomber & Sod} Inc.Box 66 J.P.Macommber & Son Inc.
enterville,Mass . 02632 Box 66' Centerville,Mass. 02632
Type of Building: ``
Dwelling XXXNo.of Bedrooms 3 Garbage Grinder`(N0) )
Other Type of Building R11 S w. No.of Persons 2 Showers( ) Cafeteria( )
i Other Fixtures
s ,Design Flow 3 3 gallons per day. Calculated daily flow 3 Y 1 n gallons.
Plan'Date 10/15/96 Number of sheets Revision Date`
y Title
Description of Soil Loamy sand to clay to fine sand.
l ,
Y•'t(
Nature of Repairs or Alterations(Answer when applicable) Adding 3-330 Recharge to an exi a+,ing
1000 gall on .tank—and leach pit. Distribution box `
Date last inspected: 10/1 5/9 6
Agreement: `
The undersigned agrees to ensure the construction and maintenance of the afore described-on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code:and-not to place the system in operation until a Certifi-
cate of Compliance-has been issu d b s Board of Healtk.
f y, '•, Signed '� Date
10/15/96
` � 1
Application Approved by Date Alf "f
Application Disapproved for the following reasons {F r
N,
Permit No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
1.
BARNSTABLE, MASSACHUSETTS t!
i
Certificate of Compliance ;
THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced(XX)on
rb?r: Bruce Lovejoy Installer J.P.Macomber & Son Tnn.
at 31 Ryder Lane Cumma uid Mass. h4 been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Pe t No. .3 X6 dated /d --1l—
1 Date Inspector
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAVrHE SYS-
TEM WILL FUNCTION SATISFACTORY.
. ��/ � �a -------------------------
No Fee 50.00
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Oigpogal *pgtem Congtruction Permit
Permission is hereby granted to J.P.Ma e o mb e r & Son Inc.. ..
to construct( )repair(`4an On-site Sewage System located at No.#
31 Ryder Lane Cummaquid,Mass .
Street Q
and as described in the above Application for Disposal System Construction Permit.
No. Date
The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions.
All construction must be completed within three years of the date below.
Date: / lt!p -Approved b /
PP Y
Board of Health
! EE' tI�iCA`iION OIL SKE'fCll AND APPLICATION FOIZ A DISPOSAL
FORKS CONSIRUC'I'ION PL'ltly,11'I' (1VI'I'flOU'E' DESIGNED PLANS
I, Joseph P.Maeomber Jr.._, t,trrby certify that the application for disposal works
construction permit signed by mu dii!ed , concerning the
pr,)perty located at 31 Ryder Lane_ Cummaguid,Mass. meets all of the
following criteria:
• There are no wetlands within 300 beet of the proposed septic system
• There are no private Wells witllkl 150 1'i:et of the proposed septic system
• The observed groundwater table: is A Cccl or bleater below tile.bottom or the lcaChillb faCillty
• There is no increase in flow ancvor 0:nee in use proposed
• There are no variances requested or needed.
SIGNED
DATE: 10/15/96
LICENS~D SEP"I'iC SYSTEM INSTALL 1 IN '1'l-LC"I'O\VN OF BARNSTABLE NUNMER
(Attach a sketch plan of the proposed system. Also if t11e licensed installer posesses..a certified plot plan,
this plan should be submitted).
,f
'~ New
3-330 .Rechargers
Existing 1000
gallon leach pi
New Distribution box
0 xisting 1000 gallon tank
31 Ryder ane Cummaquid,Mass .
1�
31 RYDER LANE CUMMAQUID COTTAG BASEMENT PLAN
—'------189— --3'9---^ g't 1- _i—5'3 18'5--------- '`
1
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1 � I
CRAWL-ADDITION `
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j FULL-EXISITING O
I ,
i
FULL-ADDITION
I 1 to iry
I �1 r I I
j I j
I I 45— j
23' '_ I
1n DECK FOOTINGS
47 18' 1015 127
-- 227 T 23 _
1 I
527
DECK FOOTINGS
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THE COMMONWEALTH OF MASSACHUSETTS /ry�J✓�J �/ � /
BOARD OF HEALTH
_> 3�
..................OF....... .•_...........................
Appliration for Uhipmal Workg .Tandrurtion rautit
Application is hereby made for a Permit to Construct ( 4r Repair ( ) an Individual Sewage Disposal
System at
.. _
- --------------------- ..................... ... � : ._......._............_......._..........._.
! � G..�s..-... daf�n-Add/ / ----- /�� 1 .o' .Y�.O
-----------------•------- . ..._......... . ...-s
r ' /
ddres
�4 Installer Address
14 Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
a 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 ( )
•-' Percolation Test Results Performed by----------------- ........................................................ Date.........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a --••--•---• .....-- ...............
0 Description of Soil.............. ...._.. _..•- �AI- -----
---------------•-.--_..
U ---••-•-------•----------------••-----••---••------....•-------.....--------------------......._...........------------......_....-•-----------•----
U Nature of Repai or Alter ions— swer when applicable____�...._.,�(� .....___ .._.-+�-0 .._e......�.....
---------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITL% 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....4�._. �� .y+ :. ..................... ........... Z......
Date
Application Approved By. ••-- ..-1-ate
Date
Application Disapproved for the following reasons---------------•---......--------••--•--------•--------------•---•---------------------------•--•-•..........__
--••-•---•------------------------•------••-•---------------..--.........-----..............--------•---.-----------••••----•--•....--------•-•----------••-----•----•-•--•-•-••------••••...-----.-----
Date
PermitNo.......18--..11. ...... ... - Issued-.......................................................
Date
��.. ................... ___________________________
_%� .._.�1.:1. I ._. Fss_.f...�%. .J
THE COMMONWEALTH OF MASSACHUSETTS .
BOARD OF HEALTH 35/
O ............. OF...... ���-N... .IIJ..:.1'.1.1_�.-----..........................
Appliration for Disposal Works Tonstrur#ion Frrmi#
Application is hereby made for a Permit to Construct (V/) or Repair ( ) an Individual Sewage Disposal
Systemat• ............ C ./ ....................... ............... .. . . ..�
...........�Lo'c .. -Addresses^ - o. ...................................................t No.
......... - � ....-:a..,�n- .� _.....------•----.-•----.
---_...... ....................................... ye._ ..::..:............ ---- ............
a 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 ( )
(3.1 Other fixtures ....................•--••-------------------•-- `'.
d ------..--•--------------••-------•---------•••-- ................
Design Flow............................................gallons per person per day. Total daily flow.._.................---.-----...._.. gallons.
Septic Tank—Liquid capacity........_...gallons Length................ Width................ Diameter.............._. Depth................
x Disposal Trench—No--------------------- Width.................... Total Length.................... Total leaching area...................sq. ft.
3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
14 Percolation Test Results Performed by.......................................•-....----•••-----.....-•-......... Date........................................
� Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ............................ ----:.................. ... .....
.-....
.......
-........
...._..........
•....
........
--------------
•......
........
....
O Description of Soil------------' sJ.. , .
r, ----------------------------
------------------------
................
-------------------
...............
........ ......
-....................
.......
--.---------
---------
._......................
.......................... ------------ -----•--------------------.............--------•--•------------•--.................-----------.................. ..
U Nature of Repair s or Alt tions=Qnswe when applicable... ..__..! r� ... �........ ... .....:......
....
,4
Agreement
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. G
Signed...�•-�: ��-------------------•--•-- 3'- I w Ov
Date
Application Approved B ............ ..ellDate
PP PP Y _.. -..-�- r -."` .............
Application Disapproved for the following reasons:..........................................................................................................---
•----•...................•---........-----.....-•-------•-------------------------------...................-----•----........--•-----.........------........---......................_.......-•••.---•--
r �
PermitNo.. ¢=-•--..---�----•....-------•----.._.... Issued.............................................ate
Date -------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
`...........OF........ 4i -1—Do --------------------------
Trrtif irate of Toutplinurr
THIS�IS�TTP CERTIFY, That the Ip$ividual .ewage Di posal Syst oo tructed �) orRepaired ( )
by.........:...... �-L--'t. S.....� /��? ......�s�6±'J -.... :.�......_......_....--••--. ._...._
Install
at....... .......... l d ,... - ...........e_-2..�.� .N.
has been i stalled in accordance with the provi�s of TIT 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No....... ..-_L.7..._....... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE....................,. - ............................... - Inspector...... �-M............................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O - L H
................ 'OF.... 1 �!/ ......6- :............................. ) • CA
No.......6...... �. Fss...,/..................
Disposal Works Tonstrur#in 2 .
Permission Is ereby granted......... �..../� :._d..'. ^�f '............`...................... ... ��_
to Construct ( r R air ( ) Individ Sewage Disposal, ,System
at No...----.... • �...... ,tl l.,.. > r��-'-'.�' �!�e.,... ....��:�._ .....................................
Street
as shown on the application for Disposal Works Construct n Permit o.. /! .... Dated..........................................
...-----• . •.. ........4...= =_"`......................................
t
DATE................................................................................ Board of Health
FORM 1255 A. M. SULKIN. INC.. BOSTON
i t � - sNE�i' � a •rNct�Ts ..
• Jam/ T� ��/_}—T./ j F,3
LOCATIONi9/?!e%ST�
SCALE . . //i.. �a�. . DATE
PLAN REFERENCE
. :-5/-lt>,I•�i!�!, Gov'. �� . .`3.-�/. . . . �, '"
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . �.\cq�G� \ ��`�.� obi z�✓�� r
28
i
3gi /
03
9 /
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o-
7vP of
X L-yiSTi,/�g /.o w
19
�T
` J
OF
•• � KELLEY
!` No. 26100 ,=o
f?e�cE �. �'f3�f?FYf2A T �o
Ail`'
TOP OF FOUNDATION
° CONCRETE COVER
CONCRETE COVERS
4"CAST IRON 12� MAX. r
12'•MAX.
OR SCHEDULE 40 4"SCHEDULE 40 P.V.C.(ONLY)
P.V.C. PIPE PIPE - MIN. P2C ,S�
PITCH 1/4"PER.FT. PITCH 1/4"PER.FT
o•° DrF��ru
INVERT CZ per,
e EL..37,94. INVERT INVEff
SEPTIC TANK 3 6 DI ST.
EL... -. . . . . F-
;,c INVERT /p®p , GAL. INVERT _ BOX r U a ;:;; 3/4"TO 11/2 a; EL.. r INVERT
EL��... °;. w w
� EL3Z.ac ; • WASHED
4-7/ c�,3/,0� STONE
—� o r ----
PROFI LE OF GROUND WATER TABLE
SEWAGE DISPOSAL SYSTEM
NO SCALE
SOIL LOG WITNESSED BY
DATE &LlC. 30/.fbIf- TIME./,O;.00 �N'7 BOARD OF HEALTH
TEST HOLE i TEST HOLE 2 lee ENGINEER
ELEV. r3Gr-PP . . . ELEV. ,��+4. . .
46 Itso c. DESIGN DATA
EZ.3Z,on �
Fins NUMBER OF BEDROOMS 7fc�?/S�•t"�/
CoSE �Z,3q�La TOTAL ESTIMATED FLOW . . ��� , . . GALLONS/DAY
Co%trz��
SA'►v0 84� wgv�z BOTTOM LEACHING AREA . . . . SQ.FT. /PIT/G;
�oA7-sue SIDE LEACHING AREA . . . . . . . SQ.FT./ PIT//4.
L2,ZC,oc� Z�jLU GARBAGE DISPOSAL Nv�/E (50 % AREA INCREASE)
CC� �LAy TOTAL LEACHING AREA . ZSZ. . . SQ.FT
/ , PERCOLATION RATE .7WO MIN/INCH
low LSZ.Z¢on /3L tt. ZB,tc�
LEACHING AREA PER PERCOLATION RATE . 33�.
.P�".WATER ENCOUNTERED . SQ.FT./G,r?�
..� '
7f8T Now i°-Z o/vL�/ NUMBER OF LEACHING
APPROVED . . . . . . BOARD OF HEALTH
DATE .
AGENT OR INSPECTOR
0F16 OF
n�
KELLEY
No. 26100 a
L LM%Z;. d TEA
PETITIONER �? � �� 7— (tiVL-aTv,/
P- � 3Zo
TAT d—lz
Lam
01
Sv-a—so/ L
4n.3/-tea
Hti�s
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1
OF
-'E.
?i . KELL EY
tq No. 26100
�sSrgf�IS�4R�`� ���
LA��
I
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k0CAT N SEWAGE PERMIT NO.
z �� _
INSTA LER'S NAIAE 6 ADDRESS
t U l l ®E R ®R ONIN Et1
0AT PERMIT ISSUED
DATE C0 Pl1ANCE ISSUED _
Y
=o r
z�
BUILDING 0z
0� t.
TOWN OF BARNSTA ��, ASS�C iUS� J
r'{ TTS PERMIT VALIDATION z
A=351-35 _ g s!�.
✓. DATE March 10 I s 83 - 2 .n Q r PERMIT NO._ 2 4 H r APPLICANT Owner
Y � Y ADDRESS 0004 ��
4�� Y (N0.) (STREET) L' (CONTR S LI.CENSE),as
Add to dwellin y
�Fi Y PERMIT:TO' _(_) STORY_ Single fajjl] ( dwe i g NUMBER OF # „Yy
F•+' (TYPE OF IMPROVEMENT) N0. DWELL ING"UNITS
t'� t (PROPOSED USE)
t AT (LOCATION) — 31 Ryder Lane, Cummaguid 20NING
)'qq4 (NO.) (STREET) DISTRICT'' F s�
BETWEEN
(CROSS STREET) AND }
(CROSS STREET) '': •rr ,,.,�,; .'
T';,m.SUBDI.VIS ION LOT
LOT BLOCK e
r SIZE y 4'
aE.
At0 •BUILDING IS TO BE FT, IDE BY FT r T'
m W , LONG BY FT: IN HEIGHT AND SHALL CONFORM IN CONSTRUCTION 0 -*_
"Z`-TO.TY PE USE GROUP
BASEMENT WALLS OR FOUNDATIONIx
'
y O
� (TYPE)_ -
REMARKS: NO SEWAGE
F_
ray' AR
-, EA Add '105 Sq. ft. At
z" 2,000.00 PERMIT $ �r
[6 (CUBIC/SQUARE FEET) ESTIMATED COST . FEE 'S•.00''
} `.� x _ +
+ OWNER Bnice Ro IAVe] ^
ti o ADDRESS BOX 615 Barnstable MA BUILDING DEPT.
}� BY -
a ,
j1�t�IdOyit on P?E:�....;�: ,,:C3 of d - ,
- c agent of owner)
,— _ -- - -
Y
a
t
3 �
z
F.ASf��S'SOR'S MAP NO. .ti PARCEL
AT
"I SEWAGE PERMIT NO.
-3
V'I L G E
Lena
INS TA LLE 'S NAME i ADDRESS
B U I L D E R OR OWNER
DATE PERMIT ISSUED
I't
DATE COMPLIANCE ISSUED
i
i
0
Q
n �
a i
� i
r,
T
2a'
o -
kCRipJ
TOWN OF BARNSTABLE
LOCATION 7 f A L4 6c_y,— s.W. SEWAGE # '")/ 7
SY1� :� Fti �a
V_YLLAGE ✓tlti,a�,1 (i:y�,P� ASSESSOR'S MAP & LOT ,
INSTALLER'S NAME & PHONE NO. , 6,413
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) jri�� (size) /i) F
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
m
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes 'No ��
�;
�:��
� ���:
��
-���cR
fy _
f
r:1 N��
•_.
No........ Flmla... ..............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEAL H A- J
ApV tratgon -fur Bhipoiitt1 Workii TouBtrurti rr�tit
Repair an Individual Sewage/Disspoa
Application is hereby made for a Permit to Constructor Repa ( ) a
System at: ' ��-
-------------•
ocation-Address Lot o.
• - •--- -•• --•- •--------------------•---
Own ,/ Address
Z�
Installer Address
Type of Buildine'll- Size Lot----------------------------Sq. feet
U Dwelling i— E
No. of Bedrooms____________________________________________ xpansion Attic ( ) Garbage Grinder ( )
a, 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. it.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by------------------------------------------------------------------------- Date-------------------------:-------------
,� Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.........---------------
L14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-----------._-----_..___
rx p . -
O
------ ----_ ----- %� - ---Description of Soil------------------- ------------- - ---- � -------------------�-------
U4 •----------------- ---•----• r - ,---------
W ��C 1 - --------- ---- _- �;._.
x
U Nature of Repairs r Alternt s—A s er h a plicable... fi . _ l ___ .__ ...__ ��-
-•------••-------------•--- ... __. �/�j� - --�-----• g
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article \I of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b issued by tie b rd of health.
Application Approved BY Signe._.. .- - v - //!f Date
I
1Yace
Application Disapproved or the following reasons:PP PP f -----------------------------------------
-------------•-•••-•--•---•-------•._....-•••--•-----•--------------•--•-•-•-•---••••-••---•--------•----•------••-•------------.._...--•---------------------------. ---------------------------------
Date
7G •-•----_.....Permit No.--------•---------------•---------••-------------------. Issued..---�--- ---1--- - f --
D e
tarrat
No........0.9-L._41
.. k r Fina... r
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEAL H ^
Ie • �... OF......... ,��''L '.. -----------
Applira#ion -for Di_gpviial Wark,6 Tonstrurtj n Prrmit
Application is hereby made for-a Permit to Construct ( ) or Repair ( ) an Individual Sewage Dispo al
System at:
--------------
w
ocation-Address r LDt NO.
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............ ..... _ .. __. __..__._..._--. :_ ...__.. _ _ ____--•__.-_----. ------
w. w r Ad.r
ess.;
W . --- ---� --•------- i.. --•--•-•-`-----------------------------------------------------------------------------------------
Installer Address
Q Type of Build Size Lot---------------- _ Sq. feet
U Dwelling.:---No. of Bedrooms..._ ) ansion Attic Garbage Grinder
g.. - ----- -- ------ --P ( ) g ( )
p, Other L Type of Building ------------------ -- ---- o. of perlo is_-_._____._____________.____ Showers,( .) — Cafeteria ( )
Other fixtures f--------------------4...... ::.....
Design Flow............................................gallons pei- person per day. Total daily flow............--------------------------------gallons.
Septic Tank—Liquid capacity-_._-_----gallons Length;_______________ Width................ Diameter_...____..-_.-. Depth.-..-.--__....--
xDisposal Trench—No- _____________________ Width---------------{._.. Total Length_._--_-_-_------___ Total leaching area--------------------sq. ft.
Seepage..Pit'No..................... Diameter-_--____:___..__---_ Depth below inlet.....................Total :eachin- area.--_-.-._--__---_sq. tt.
Other Distribution box ( ) Dosing tank ( )
Percolation Test,Results Performed by ..................... Date--------------------------------- ------
Test Pit No." 1_________________=-uinutes per inch Depth of "Pest Pit.................... Depth tc ground;water_.----____-_--
�14 Test Pit No. 2................minutes per inch- Depth of Test Pit---------........... Depth to ground water._.--.-.--.-___._-_--._.
a ------------------------------- . • ...............
D Description of Soil " ---------------- --- ---"�----` - . .
x r 4.✓ ,
U ---------- - -------------- - - .......-----•----- ............ .---- ........... - - --- - - ---------- --
f �
UW ------------------------
Nature of Repairs or, Alt s— n plicable_-:-_ `
-------------- L: < r - --... fiE : -- --- ---------------._-....
Agreement: 210
The undersigned -agrees to install the`aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation.until a Certificate of Compliance has bee issued by',the b d of health.
' s ' r
Sign -- --------••--=-----•---- -- -----------------------
€.
o Dat
APPlication Approved BY = /� ate? 3 ...
Application Disapproved for the following reasons.
r
Date
yo+
Permit No........................................
.............:.:: Issued.----------------------------=--•------------•--------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
f
Trarfifirafae off�aamIi�t�crae
TH S I TO CERTIFY" hat the Individual Sewage Disposal System constructed ( ) r Repaired
by....... .. .... .. ..... •- • -—-•--------•-- ------------•----------- . ----
�y Installer,
at.... sLi - . ;Ir
.... .. •. •. ........
has bee n ailed in acco`rdanc.e with the provisions of Artic� 1e�I The State Sy ode as described in the
application for Disposal Works Construction Permit No............ / _-___-_-- dated...._... .y",,__.f�_f--- ----
THE ISSUANCE OF THIS CERTIFICATE SHALL,NOT BE CONSTRUED AS A GUAR; TEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. `
DATE = - -= ,..__•---• Inspector......................................................................................
THE COMMONWEALTH OF MASSACHUSETTS . ... yy►r [1 �+
BOAR Dx OF H ALTH
y N
No. .� l f/- FEE__ ........
i �aaa ttl k QIT aa str boat Urr.mit
Permission is hereby granted__,_- " �_ ...
to Construct ( ) or Repa' an ndiv al Sewage Disp ystem `
r ,
at No. Y------
fib
as shown on the applicat o for Disposal Works Construction Pe rt tNo._ Dated___._.._.
�-.�/, ..>
B r of t
DATE=------------
FORM 1255- ,HOBBS & WARREN. INC.. PUBLISHERS •`
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ILL)OR DECK ( GALLERY
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BATH
STORAGE 3s y 67 4.2- BUILDING
OORSx2 I SETBACK 1 5'from
EDGE OF
PROPERTY
JSCREEN
Pine SCROLL i SCROLL RAWERS
WINDOWS
CJSCREEN LOSET
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5 EXISTING
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EXISTING II
1 STONE WALL DECK WITH RAILING
STAIRS
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BELOW-
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CEDAR TREE I I v
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S`,LIVING AREA SEPTIC APPROVED
DESIGN FOR 3 ( I I
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I APPROXIMATE LOCATION FOR
1„ MOVEDI BOX
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Field still another 20 feet to thre
north
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