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HomeMy WebLinkAbout0041 STONEY POINT ROAD - Health 41 Stoney Point Roar! Barnstable P A = 336 041 e a ' w o " o m .aS si ih r o , COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION F I yt RECEIVED ~ SV 6 JUL 1 6 2003 TOWN OF BARNSTABLE TITLE 5 HEALTH DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A 3 CERTIFICATION MAP PARCEL 4- Property Address: 41 Stony Point Road,Cummaquid,MA-Barnstable LOT Owner's Name: Cathy Viola and Patrica Anderson Owner's Address: 41 Stoney Point Road,PO.Box 14,Cummaquid,MA 02637 Date of Inspection: 6/30/03 Name of Inspector: REED C.ELLIS Company Name: ELLIS BROTHERS CONST.CO. Mailing Address: 23 ENTERPRISE ROAD, P.O.BOX 59,YARMOUTH PORT,MA 02675 Telephone Number: 508-362-6237 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 fund and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to ection 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: 104 V v l Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to 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. 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:41 Stony Point Road,Cummaquid,MA Owner: Cathy Viola and Patrica Anderson Date of Inspection:6/30/03 Inspection Summary: Check&,C D or E/ALWAYS complete all of Section D A. System Passes: LA MOI have not found y 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"section need to be replaced or repaired The system,upon completion of the replacement r repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the foi the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or th a septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as ap roved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available ND explain: Observation of sewage backup or break out or high tatic water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven dis ibution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are repiced obstruction is removed distribution box is leve led or replaced ND explain: The system required pumping more than 4 times a y ar due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are repla obstruction is removed ND explain: F 2 i Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 41 Stony Point Road,Cummaquid,MA Owner:Cathy Viola and Patrica Anderson Date of Inspection:6/30/03 , C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Bo d of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will prote 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 vege ated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public I Vater Supplier,if any)determines that the system is functioning in a manner that protects the public he alth,safety and environment: _ The system has a septic tank and soil absorption syste (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 v ithin a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is v ithin 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is li ss than 100 feet but 50 feet or more from a private water supply well".Method used to determine dis ce "This system passes if the well water analysis,performed A a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the 11 is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is eqt al to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be ittached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 41 Stony Point Road,Cummaquid,MA Owner: Cathy Viola and Patrica Anderson Date of Inspection:6130103 D. System Failure Criteria applicable to all systems: You must indicate"yes"or`no"to each of the following for all inspections: Yes No _ ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or logged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or V e poolquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number � A tunes pumped V y 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 *ater supply. y portion of a cesspool or privy is within a Zone 1 of a public well. y portion of a cesspool or privy is within 50 feet of a private water supply well. y portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria a triggered. copy of the analysis must be attached to this form.] a" Na� �o The stem fails.I have determined that one or more of the above failure criteria exist as �' ) system 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 orrect the failure. E. Large Systems: Y To be considered a large system the system must se e a facility with a design flow of 10,000 gpd to 15,000 gPd• You must indicate either"yes"or"no"to each of the fol owing: (The following criteria apply to large systems in additior to the criteria above) yes no _ the system is within 400 feet of a surface drint ing 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 ar (Interim Wellhead Protection Area—IWPA)or a mapped Zone lI of a public water supply well If you have answered"yes"to any question in Section E i he system is considered a significant threat,or answered "yes"in Section D above the large system has failed.Th 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 41 Stony Point Road,Cummaquid,MA Owner: Cathy Viola and Patrica Anderson Date of Inspection: 6/30/03 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: e No ping information was provided by the owner,occupant,or Board of Health _ Were any of the system components pumped out in the previous two weeks'? v as the system ?sy a received normal flows m 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? Were all system components,&*cluding the SAS,located on site? Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition !of th aflles 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: Ye 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 CMR 15.302(3)(b)] 5 I - Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 41 Stony point Road,Cummaquid,MA Owner: Cathy Viola and Patrica Anderson Date of Inspection:6/30/03 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): J Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): �3 Number of current residents: I D Does residence have a garbage grinder(yes or no): /U Is laundry on a separate sewage system(ye or no):—mg[if yes separate inspection required] Laundry system inspected(yes or no):�' Seasonal use:(yes or no): Water meter readings,if available(last 2 years usage(gpd)1:5�; Cul -a 09- 371L, 9_002� o9,003 4164 Sump pump(yes or no):A QW I-I3'A ta— �N s i d U UA&, g 3 u Last date of occupancy: I (;U 1 COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or n ): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records 69���4 AD Source of information: Was system pumped as part of the inspection(yes or no): � If yes,volume pumped�Qj�gallpns--How was quart' pupiped determined? L �'� � — Reason for pumping: jZ g_ —��y�/oL (�•p! -�—� 7E 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): Approximaqte age of all components, installed(if known) d s urcece of inform on: 9 �Sl G,' ci Were sewage odors detected when arriving at the site(yes or no).,&0 6 Page 7 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 41 Stony Point Road,Cummaquid,NIA Owner: Cathy Viola and Patrica Anderson Date of Inspection: 6/30/03 BUILDING SEWER(locate on site plan) Depth below grade:_ Materials of construction:_cast iron V40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of le cage, t 11J Ce UA/l-, v l N 1A Ced SEPTIC TANK: locate on site plan) Depth below grade: P1 N�f" S.lk �'�- L a Material of construction: concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) � Dimensions: q Sludge depth: �F Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: y How were dimensions determined: V4 ,L . . — Comments(on pumping recommendaat ons,inlet and outletlee or baffle coVdition,structural integrity,liquid levels fated to outlet inv rt,evidence of leakage etc.): , 4 0 1 b n1a� l� GREASE TRAP:_(locate on site plan) Depth below grade: Material of construction:_concrete_metal_fi rglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffl : Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 41 Stony Point Road,Cummaquid,MA Owner: Cathy Viola and Patrica Anderson Date of Inspection: 6/30/03 TIGHT or HOLDING TANK: (tank must be pum ed at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal—fil ffglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: Pof 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.): Affl/' PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition c f pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 41'Stony Point Road,Cummaquid,MA Owner: Cathy Viola and Patrica Anderson Date of Inspection: 6130103 SOIL ABSORPTION SYSTEM(SAS): 4ocate on site plan,excavation not required) If SAS not located explain why: Type ,,leaching pits,number:_ leaching chambers,number: ?✓' ��1 �, �"� 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 oi ydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): 0A1 Q�, Gvf v7s m CESSPOOLS: (cesspool must be pumped as p of inspection)(locate on site plan) Number and configuration: FPS ! Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic fa ure,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 ilure,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: 41 Stony Point, Road,Cummaquid,MA vvv�A/ ",� � C Owner: Cathy Viola and Patrica Anderson Date of Inspection: 6/30/03 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. I� 04 lr a r 3g0��MoN"a�F9n�I►� �, y �,�u 1` 3 7' ' L . 3 10 Page 11 of 11 FFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 41 Stony Point Road,Cummaquid,MA Owner: Cathy Viola and Patrica Anderosu Date of Inspection: 6/30/03 SITE EXAM Slope Surface water /1/pA_ Check cellar D'4/r Shallow wells ��l 10 J ����� �y�•y� /�,'r Estimated depth to ground water Please indicate(check)all methods used to determine the high ground water elevation: 66 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,installer -(attach d��ocyym tati ) Accessed USGS database-explain: AIM, 03 You must describe how you established the high ground water elevation: 1u � -7-7 �K —�8 rl. Zv l/►�1,�N . 4 r�-A�va W '0►w�- ?� ti 11 � 2 l �• �!' � TOWN OF BARNSTABLE LOCATION &W � ' " ®� SEWAGE # VILLAGE C �` AfVAP'La't'�fASSESSOR'S MAP & LOT ZiNSTALLER'S NAN4&PHONE NO. IA cArvn /� ��S 6irily(I�ofS' C '1 SEPTIC TANK CAPACITY LEACHING FACILITY: (_Pe) (size) NO. OF BEDROOMS BUILDER OR OWNER Cel0'�v`7 PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water SuppirW. ell and Leaching Facility (If any wells exist on site or within 200.feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching:facility) Feet I� Furnished by �� LJ Q.z 396" 3 �o f - COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED FAILFn ,NSPECTI®N MAY 0 6 2003 TOWN OF BARNSTABLE TITLE 5 HEALTH DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION `j,L ZOO Property Address: /010 A01.17T tft4l v"/ L", Owner's Name: A-1 i-A // o � MAR 33 Owner's Address: iQ k7oiH / / PARCEL, Gl.btcr oZG 3 Date of Inspection: 9 03 LOT ; Name of Inspector: lease print) Company Name• -- Mailing Address: Po av-x ;47 6 Y�4 Telephone Number:(Slvs _ 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 15.3.30 of Title 5(310 CNIR 15.000). The system: Passes Conditionally Passes <eds Further Evaluation by the Local Approving Authority ,y-- -Fails Inspector's Signature: G�i�L Date: //C Ir The system inspector shall submit a copy of this inspection report to the ApproNing Authority(Board of Health or DEP)«ithin 30 days of completing this inspection. If the system is a shared system or has a design flow of I0,000 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 andsComments ****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- r Page 2 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: �oIle Owe /] / � a�,Owner: Date of Inspection: �9 Q Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: 6 have not found any information which indicates that any of the failure criteria described ' 15.303 or in 310 CNN 15.304 exist. Any failure criteria not evaluated are indicated below. ui 310 CivfR Comments: Z;c Conditionally Passes: or more system components as described in the"Conditional Pass"section need to be replaced or system, upon completion of the replacement or repair,as approved by the Board of Hcalth,will pass. Answer yes, no or not determined(Y,N,ND)in the for the following statements. If"not determined"please The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,e:thibits substantial infiltration or erfiltration or tank failure is imminent. System«ill pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank gill pass inspection if it is structurally sound not lealdng and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system«ill pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: _SyoEj v� 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 determine if the system is failing to protect public health safety or the environment. I. System will pass unless Board of Health determines in accordance with 310 Civ1R 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 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 pprr,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: h r Page d of I l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A. CERTIFICATION(continued) Property Address Owner: Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no" to each of the following for all inspections: Yes No/ Backup of sewage into facility or system cozponent 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 S tic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or esspool iquid depth in cesspool is less than 6"below invert or available volume is less than%:day flow Required pumping more than 4 times in the last year NOT due to Clogged or obstructed ptpe t of times pumped / (s).Number mberAny portion of the SAS,cesspool or pmy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface%titer supply or tributary to a surface z1azter supply. v portion of a cesspool or privy is within a Zone 1 of a public well. typortion of a cesspool or privy is within 50 feet of a private water supply well. portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well «ith no acceptable water quality analysis. [This system passes if the well water analysis, m NCrfore•' DEP certified laboratory,for coliform bacteria and volatile o banic compounds indicates t.;,. cne 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 arc tribecred.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 s%.sterr. the system must serve a facility,with a design flow of 10 -H)0 gpd to 15,000 gpd• You must indicate either"yes' or"no" to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ — the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA) or a mapped Zone II 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!�-e 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. r Page 5ofII OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address• �� n �� Owner: ac 3 Date of Inspection: Check if the following have been done. You must indicate`des" or"no" as to each of the following: Yes No Pumping information was provided by the owner,occupant, or Board of Health _ f//Were any of the system components pumped out in the previous two weeks V Has the system received normal flows in the previous two week period "ve large volumes of water been introduced to the system recently or as part of this insPec Lion Were as built plans of the system obtained and examined?(Lf they.were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up Iz— 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 I'eb— Was the facility owner(and occupants if different from owner provided with a di )p h 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 anv of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CNIR 15.302(3)(b)) Page 6 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C � � SYSTEM INFORi�1ATION PropertyAddress• T �TfJ�� Q10 Owner: [� (Q G Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):C2— Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): O2ol ' �c� Number of current residents:_ / Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(ves or no): -o if yes se Laundry system inspected paste inspection required] pe (yes or no): 9 Seasonal use: (yes or no): &) Water meter readings, if available(last 2 years usage(gpd)): Sump Pump(yes or no):Qa,� Last date of occupancy: rg,� COMINIERCIAUIND USTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/scActc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title S system(yes or no):— Water meter readings,if available: Last date of occupancy/use: OTHER be): Pumping Records GENERAL INFORMATION Source of information: Was system pumped as part of the inspecti (yes or no): If yes,volume pumped:_gallons--How was quantity pumped determined' Reason for pumping: TYf OF SYSTEMV_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 components,date installed(if known)and so=e of information: Were sewage odors detected when arriving at the site(yes or no):zV— O Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: I� 7_ 12d Owner:—Y�O /�' v�l wt ©-ZC 3 59 Date of Inspection= BUILDLNG SEWER(locate 9�site plan) Depth below grade: Materials of construction: L.Xcast iron _( O PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction: concrete_metal_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: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to botto9�of/outlet teeAr baffle: �G � "I How were dimensions determined: 1�4 Comments(on pumping recommendations, inlet and outl tee or baffle condition, structural integrity, liquid levels as,c lated to outlet invert,evidence of leakage, etc.): !�� HY7 m heed G. o e—k GREASE TRAP; (locate on site plan) ~ Depth below grade: Material of construction:_concrete_metal fibergs lene other (expWn): — las _polyethy _ Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTENI INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address- Ac Owner: �QU/ h� y R Q �!' a)-6 7�- 1 Date of Inspection: TIGHT or HOLDING TANK:&L" (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: Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float stivitches,etc.): D •-.-r.0 D.,... V 1STRLB G i 10"J 01-1 _ �( present must be opened)(locate on site plan) Depth of liquid level abo%_ .. invert: OO✓PWC4� Comments(note if box is ic•.cl acd distribution to outlets equal,any evidence of solids carryover,any evidence of l ge into ocout of x,etc.): oX t S o, �r�cue _ �S �0 S r o � PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: S C N e wlvyc,C�u i Owner: Date of Inspection: 0 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type — �( Q Ll/�l SQ ►� leaching pits,number: f' leaching chambers, number: 3 leaching galleries,number: J 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 veetation etc.):�// /� g r _ // Ova /�.� �b Sly! /N � �?OhL' Ctlit� qr, i O - " CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: UepUi of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation etc.): PRIVY: i (ocate 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.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM IN SPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: A01 Owner �, l 0..,C-7 Date of Inspection: 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. f / ,/) � o � - .�� � g,,,,#0 Z--1�7 k« 7--- 17 S J, �e Page II ofll OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: � jjv) ""r�7 !r00IA Q t-t Owner. / Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) �r� Accessed USGS database-explain: • / You st descri how yo established the hi-h gr and water levation: / /'o Lr�r l.✓�ye.ti a 451 6OX r �® (ills �1j 67 l©u Cj � 9 - 1 Wm. E. Robinson, Sr. Septic Service P. O. Box 1089 Centerville, MA 02632 775-8776 Fax 790-1694 mil a -zoo ? e.-I)XOM dm eavemr-lv ed (571 0 AC -i") E&# '0�00&609�ot A7- -00 � -0 - �, CO o r COMMONWEALTH OF MASSACHUSETTS EXECUTIVES OFFICE OF.ENVIRONMENTAL AFFAIRS DEPARTMENT'OF ENVIRONMENTAL PROTECTION' TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS''' SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 41 Stoney- Point Rd. Cummaquid, MA 02637 Owner's Name: Kathy Viola Owner's Address: Date of Inspection: Name of Inspector:(please print)yli l l i am F._ . Rohi nson Sr. Company Name: William E. Robinson Septic Service Afailing Address: P .0._ Box 1 089 _Centerville, MA Telephone Number: ( S O n l 7 7 5—n 7 7 6 CERTIFICATION STATEMENT 1 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(3I0,CA'IR 15:000 The system: Ll�Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails — Inspector's Signature: Date: - '' t • 1 The system inspector shall submit a copy of this inspection report to the Approving Authority.(board of Health of 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 to the future under the same or different conditions of use. Title 5 Inspection Form U1512000 page I Page 2 of i 1 At OFFICIAL INSPECTION FORM NOT FOR V OLUNTARY ASSESSMENTS ACE SEWAGE DISPOSAL•SYSTEM INSPECTION FORM SUBSURFACE PART A CERTIFICATION (continued) RtnnPV Po�.,t-Property RA ' ProP a Address: 4___ 1- -- Cumma Owner: Viol Date of Inspection: DorElA BC I AYS complete all of Section D; In Summary: Check A, , , A. 71tem Passes:ound any informationwhich indicates that any of the teai�ao aced belowetiA �ribed in 310 CMR have not f failure criteria not evaluated ar 15.303 or in 310 CM 15.304 exist.Any Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"ovcd by the Board of Health,will pass. repa ed.The system,upon completion of the replacement or repair, PP Ans r yes,no or not determined(Y,N,ND) in the for the following statem ents.if"not determined"please expla The septic tank is metal and over 20 years old'or the septic tank( � System w will pas Peet on if the Pilure is unsound,exhibits substantial infiltration or exfratration or tank ved by the Board of Health. existing tank is replaced with a complying septic tank as app and if a Certificate of Compliance •A metal septic tank will pass utspection if it is structurally sound,not leaking indicating that the tank is less than 20 years old is available. ND explain: =-- Observation of sewage backup orbreak out or high static water level in the distribution box due.to broken or. i c s of due to a broken,settled or uneven distribution box.System will pass inspection if(with obs�trvcOb P P approval of Board of Health)- s are replaced brokenipipeO obstruction is removed distribution box is leveled or replaced ND explain: em Will The system required pumping more than 4 times a=mar due to broken or obstructed p'tpe(s).The - pass inspection if(with approval of the Board of Health): broken pipes)are replaced —obstrttctkm is wwycd ND txplain: .rage 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART:A• CERTIFICATION(continued) Property Address: - 41 . Ston y Point Rd Cummavuid, MA 02637 Owner: Viol Date or Inspection: C. urther 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 failin to protect public health,safety or the environment. 1. stem will pass unless Board or Health determines in accordance with 310 CMR 15.36(1)(b)t6a`t the system is not functioning in a:minnei which will protect public bealth safety and"the environient: Cesspoof or privy is within So feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,Iran I y)determines that the system is functioning in a manner that protects the public health,safety and.environmentc ' The system has a septic tank and soil absorption system(SAS)and the SAS rs within 100 feet su_rface water supply or tributary to a surface water,supply. — The system has aseptic tank and SAS and the SAS is.within a Zone I 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 SO feel or more front a private water supply well"•.Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and he presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other �ailure cn d:lcria are triggere A copy ofthe analysis must'be attached to this form. 3. Other: 3 _ Page 4 of I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A . CERTIFICATION(continued) Property Address. 41 Stoney Point Rd. ummaqui , MA 02637 owner: Viola Date of Inspection: D. System Failure Criteria applicable to all systems: Y must indicate"yes"or"no".to each of the following for all inspections: Ye 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 surfa.e 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'/I day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ Any portion of a cesspool or privy is within a Zone 1 of 5 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 So feet from a private water supply well with no acceptable water quality arnlysis,(This system passes if the well water analysis, performed at a DEP certified laboratory,for coliforrn bacteria and volatile organic compounds indicates.that the well is,free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.) (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 systP uld ho contact he Board of Health to determine what will be necessary to correct the failure. E. Large Systems:; To a considered a large system thesyslem must Serve a:factirly with a design Qosr of 10,000 gpd to IS,000 gp You must indicate either"yes'or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes = no the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-1WPA)or a mapped Zone II of a public water supply well if ou have answered"yes"to any question in Section E the systuu is considered a significant threat,or answered "y s"in Section D above the large system has failed.The Owner or Operator of EM large system considered a If ificant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15. 04.The system owner should contact the appropriate regional office of the Department. I 4 Page 5 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEhtINSPECTION FORM PART B - CHECKLIST' . Property Address:_ 41 Stoney Point Rd. _Cummactuid, MA 02637 Owner: Dale of Inspectlon: — Check if the following have been done.You must indicate"yes"or"'e as to each of the following: Yes No/ t/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? _ Were all system components,excluding the SAS,located on site? , __k_1 _ Were the septic tank manholes•uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of conswction,dimensions,depth of liquid,depth of sludge and deptfi`of scum? V _ Was the facility owner(and occupants if different from owner)providedwith.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 delermtned based on: Yes no _L„ Existing information.For example,a plan at the Board of Health. t,-' _ Determined in the field(if any of the failure criteria related to Part C is at issue'approximalion of distance? Y is unacceptable)13 10 CMR 15.302(3)(b)} 5 Page 6 of I 1 , OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY'ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION Property Address: 41�Stoney Point Rd. - Cummaquid, MA 02637 Owner: Viola • ' Date or Inspection:Z 2`I— FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 13.203(for example: 110 gpd x N of bedrooms): 0 Number of current residents: Does residence have a garbageirinder(yes or no):,o Is laundry on a separate sewage system(yes or no). [rf yes se.parale inspection required) Laundry system inspected(yes or no):�..� .Seasonal use:(yes or no): S Water meter readings,if available(last 2 years usage(gpd)): ' 01 — 39;000 Sump pump(yes or no): X,✓ — r 9;0 Last date of occupancy: 7l•� y-a — COMMERC L/INDUSTRIAL Type of cstabli hmcnt: Design flow(b sed on 310 CMR 15.203): Qpd basis of design flow (scats/persons/sgR,etc.): Grease trap pr ent(yes or no):_ industrial was holding tank present(yes or no):— Non-sanitary aste discharged to the Title S system(yes or no):_ Water meter adings,if available: Last date of ccupancy/user OTHER describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part.of the inspection(yes or no): U: . If yes,volume pumped:_gallons•-How was quantity pumped determined? Reason for pumping: TYPE F SYSTEM eplie 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) _Tigbt tank Attach a copy of the DEP approval Other(describe): Approximate age of all components date installed(if known)and source of information: P 0 ,_ s Were sewage odors detected when arriving at the site(yes or no):id A Page 7 of OFFICIAL INSPECTION FORM-=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIPK FORM PART C SYSTEM INFORMATION(continued) Property Address: 41 St-nnP9 vni nt Rd. _I'_ummanniri MA 02637 Owner vi nl a Date of Inspection: B LDING SEWER(locate on site plan) 3 Yv= Dep below grade: Mate ials of construction:_cast iron _40 PVC_other(explain): Dista cc from private water supply well or suction line: Co ents(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:�.-ocate on site plan) Depth below grade: Material of construction: oncrete_metal_fiberglass_polyethylene other(explain) If tank is metal list age:_ Is age confirmed-by a Certificate of Compliance Com li es or.no : certificate) t. ►� P (Y ) _(attach a copy of Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: ty J Scum thickness:6—/ t Distance f romloo of scum to top of outlet tee or baffle: rs Distance from bottom of scum to bottom of outlet tee or baffle: i n flow were dimensions determined: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid'levels as related to outlet invert,evidence of leakage,etc.): f , GRE E TRAP:_(locate on site plan) Y Depth Blow grade:_ Materi of construction:_concrete_metal fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: ` Comments(on pumping reconunendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as reljteA to outlet invert,evidence of leakage,etc.): i Page g of i l , OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 1 stoney one Po int t Rd. Property Address: UUM i r 02637 Owner. �Vio a Ins � Date•f I ect ioo.� 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: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (tt present must be opened)(locate on site plan) Depth of liquid level above outlet invert: r)_ • 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.): PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.-FORM PART SYSTEM INFORMATION(continued) Property Address: 41 Stoney Point Rd'. mmaqui , 2637 Cu Owner: Viola Date of Inspection: - • SOIL ABSORPTION SYSTEM (SAS): V(locate on site plan,excavation not required) If SAS not located explain why: Ai TYPe chin its number: _ g pits, r. teaching chambers,number: leaching galleries,number. leaching trenches,number,length: leaching fields,number,dimensions: ; overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): / A CESS OOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number nd configuration: Depth- op of liquid to inlet invert: Depth of olids layer. Depth of cum layer: Dimensio s of cesspool Materials f construction: Indication f groundwater inflow(yes or no): Comments note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of onstruction: _ Dimensions: Depth of sol s: Comments(me condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): �a 9 Page 10 of I 1 ' OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 41 Stone Point Rd. Property Address: Y ummaqui , A 2637 Owner:V io l a Date of Inspection: 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. j o i t I f 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_41 Stoney Point Rd. Cum id, MA 02637 Owner: Viola Date of inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water_4 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 ow you established the h1ph ground wa erelevation:. >2515 f j A a it I P� LOCATION SEWAGE PERMIT 0. L L A G E I N S T A LLER'S NAME i ADDRESS �f T I-A B U I L D E R OR OWNER TON ts coMw� c �y� DATE PERMIT ISSUED DATE COMPLIANCE ISSUED I -� � STVWF/ PC) tIQ j 4 y C EDWARD E. KELLEY REG. LAND SURVEYOR CUMMAQUID, MASS. 02637 TEL : (617) 362-2266 Town of Barnstable Dec. 30 , 1986 Board of Health Hyannis, Mass. Ref: 85-251 Pat Anderson, Lot #23, Stoney- Point Rd. , Cummaquid The sewage system was installed in accordance to the approved plan. All impervious material in the leach area and 25' beyond was removed and replaced with clean sand. It meets all requirements of Title V and, tthe Town of Barnstable Health regulations, SN Of�d�S OF MgSS9c . No.5 F e it a Reg,. P�rofess, onal Land, Surveyor III. L TOP OF FOUNDATION CONCRETE COVER - / �,� l/�.}� )• .' -- CONCRETE COVERS '71 // 1► /' ® .. 4 CAST IRON2"MAX -"7rn77.r TnYnn. . —�.. OR SCHEDULE 402 MAXAx 4 SCHEDULE 40 PVC (ONLY) { ry r PVC PIPE - PIPE - MIN I 3 Ftow '' • r PITCH I/4 PER FT -'ffi , A/i�.� .,w°. r Lq y i PITCH I/4'PER FT �L, PRECAST -- INVERT = -cc.x/ FL•ow- I /�` w/vt • EL NVERT -INVERI o r 'r`k SE s : D/%f�SnQ ___ I G-,gND [./�•y �r 40' { ! r' PTIC TANK EL .'3 G� DIST EL:'? I I� ; y a INVERT- 80 ;r I7i¢1 f (Nor Cow.S?YvG���� / v Z ( e EL %7 ---oon--- CAL - i INVEST _ INVERJ w l8 3/4' TO I I/2 - EL. EL " �a WASHED �� b' /7470 y4 j 1/ -- �__w 3/S� - STONE 1 I � PROR LE �OF GROUND GROUND WATER TABLE rye I I SEWAGE DISPOSAL SYSTEM 68 NO ti C A L E WGa�'R GeYyey"L ,�n b� � � ,.l •oj3 3a � ) 0 ) � 3po.5 .•.e,.-,f,✓•7�'yr7uNdc j I Qj � r "Z3 Y i I SOIL LOG WITNESSED BY : I /. 34zc'� .� �R DATE Vcv 7 /ye-a TIME /1 00 /rr� O , BOARD OF HEALTH 3 TEST HOLE '4 TEST HOLE "S,9 E tiL ELEV. 31 ZO ELEV. �27" , ! 'J ENGINEER 47" rP { { [IY tort/►+ 1 /� tof►�l L { { /�• J✓B-3oi ' �i i 5✓d•Sorc c I pl�ev �sr' ��" i DESIGN DATA � --c7 Z y•70 2�C7iv,cle ? I 30" l� NUMBER OF BEDROOMS 2 N t'yr+H/ 4d'' 1g`r'NO TOTAL ESTIMATED FLOW '2'2o GALLONS/DAY Fes';SSo � 1 V /vrs� - r411 T�CKy/vim S `� GSZ 11, fLG� I +jti ( /fs}�7�/i9�, i.v 7Tlf p7- 70 BOTTOM LEACHING AREA SO FT. /PIT/C.P.D. ` rix�7t' LO Qrz z7 7o SIDE LEACHING AREA �¢ SO FT./ PIT//La �.�• 3 rj fv I� sBnrrc T �1• R�f2E79 64 X �b J 7'a B'E . """` GARBAGE DISPOSAL NONE (g0 % AREA INCREASE) § I'"-. 1 IP.f HoyilT� '9'ND /Q'!R''►cED /�F7'!T W,7T/ Cle*~ -T~li>. SRn/�� x 1A.�a tr lSr� TOT-1- LEACHING AREA SQ.FT '••,� Sf �S ' , I { � PERCOLATION RATE Le35 r]yo MIN/ INCH r � 1. �rc rz � /20" ,�•_ E'L Z/ 70 /IQ [t1_Z.3_Zo LEACHING AREA PER PERCOLATION RATE /Z . SQ.FTAA fOle t $ ,a te , I a ( WATER ENCOUNTERED NUMBER OF LEACHING PITS \ f }cog/ CIS✓ I I APPROVED BOARD OF HEALTH Wi7� _ I DATE AGENT OR INSPECTOR At ti / EIhA D � � 1 E. KELLEY / �i F/IJ•`✓� � � �, Y/ No. GJ Bv'n"J r �'"• IV %',+, r�•.^e" �+ SAN�l AF�PN PtTITIUNER I I I 4 T D�rcN RePViSf7� .TsNv. Zy R,F//.s&D Ae e. /4 /'jB,s Mom - ZG Y/�7a s fr9.S� o,ti N1��9 N s�%9 L�vC`L ,f T OZ 3 5'/fo v✓n. v ti' •��►• uni Ewe o,�.��'z� Pl.�r-�✓ . ,e �//G L 7As-i fi .Tr��vE-s T..rti C.