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0097 SWALLOW HILL DRIVE - Health
fi 97 SWALLOW HILL DR, CUMMAQUID h A= 336-071 w a r D D cf 4 LOCATION q SEWAGE P MIT NO. vi'LLACE �6 0171 }. INSTALLER'S NAME & ADDRESS ID9,14 UZ F - 8UILDER OR OWNER ' YO / /%4GZf,4A1 f DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED //_30_ 77 • f r •''. `� .__ _ �� �- � .. ._,v.__..w _� ..... (! P-Y ('�, i .� .� .1{ �' I TOWN OF BARNSTABLE ¢ LOCATION C U ► V v ` SEWAGE # q1 S 1 6 2-4 ✓ILLAGE 7 S'tr'A 11 t ASSESSOR'S MAP & LOT' t INSTALLER'S NAME&PHONE NO. tJ 9 110N�t�9®62 1'j S'- 7 7 L SEPTIC TANK CAPACITY /.tQQ LEACHING FACILITY: (type) Q r�- (size) l,oo6 AA r NO.OF BEDROOMS 3 BUILDER OR OWNER PERMITDATE: -7I t i Q S COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by is pick V,6,3 3 COMMONWEALTH O WEALTH Or MA SSACHU ETT S S EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS a . DEPARTMENT OF ENVIRONMENTAL PROTECTION - RECEIVED MAY .312001 TITLE 5 TOWN F 13 DEPT.BLE OFFICIAL INSPECTION.FORM-NOT FOR VOLUNTARY AS_ SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A .. CERTIFICATION- Property Address: ld�U2/lb-mi y&_0442/ A Owner's Name: ��lkC � Owner's Address: S3 2-� J a/4 D,)�/C ee Date of Inspection: 5-1/.)32b/ Name of Inspector: please print) 1'40I��'�' Company Name: i Mailing Address: IP042elv / D 'dj / ,,4 0 PCB y� Telephone Number: �S69-- `77/- CAR94 CERTIFICATION STATEMENT f 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 ection 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes r Needs Further Evaluation by the Local Approving Authority /ails Inspector's Signature: D, y e: 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 1 Page 2 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: ac, . Owne Date of Inspection: Inspection.Summary: Check.A,B,C,D or E/ALWAYS complete all of Section D. A. S stem Passes: 1 have not found an information which indicates that an of the failure criteria y y a 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 or repair,as approved by.the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is.structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the. existing tank is replaced with a.complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or, obstructed.pipe(s),or due to a-broken,settled or uneven distribution box. System will pass inspection if(with. approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution.box is.leveled or replaced ND explain: The system required pumping more than"4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health):. broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of l'l s OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 9,7 Owne m ' Date of Inspection: S_ ? Xa 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. 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 of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh , 2. System will fail unless the Board of Health.(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: . _ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary. .to.a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone.I of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS•is less than 100,feet but 50 feet or more from a private water supply.well". Method used to determine distance "This system passes,if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the'well is free from pollution from that facility and the presence of ammonia nitrogen-and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A-copy of the analysis must be attached to this form. 3. Other: a. • _. a .. , y: ` 3 _ Page 4 of 1 l OFFICIAL INSPECTION FORM—NOT:FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Q 17 Owne 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 N 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 %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 l 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. ]Thi&systent passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is.free from pollution from that facility and the..presence of ammonia nitrogen and nitrate nitrogen.is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 3.10 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 largesystemthe system must serve a facility with a'design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes, no the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead.Protection Area—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 large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D sliall 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 1.1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIONFORM PART B CI-IECKL:IST Property Address: •' Owne ° Date of Inspection: 73/0. 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? # — __(Z/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 sighs of break out? _ Were all system components,excluding the SAS, located on site? - Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Was.the facility owner,(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System (SAS)on the.site has been determined based on: Yes o Existing information.For example, a plan.at the Board of Health. _ — Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] 5 Page 6 of 1 I ` OFFICIAL•INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION I+ORM :PART C _ SYSTEM INFORMATION Property Address: � ..�r2=L►„L � b� Owne . Date of Inspection: S � p FLOW CONDITIONS RESIDENTIAL Number of bedrooms.(.design): 3 . Number of bedrooms(actual):, DESIGN flow based on 310 C1v1R 15.203 (for example: 11.0 gpd x#of bedrooms): Number of current residents: Does residence.'have.a garbage grinder(yes or no): " Is laundry on a separate sewage system(yes or not-.[if yes separate inspection required] Laundry system inspected(yes or no Seasonal use:(yes or no): O- ... Water meter readings, i af�able(last 2 years usage(gpd)): Sump pump(yes or no : - I . Last date of occupancy: > i;�'/" ' COMMERCIALANDUSTRIALZD' Type of establishment:.. Design flow.(based on 310 CMR.15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no):_ Non-Sanitary waste discharged to the Title 5 system (yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: 3I Ito s p '-� Was system pumped aart of the inspection(yes or no): If yes,volume pumped: gallons--How was quantity pumped detennined? Reason'for.pumping- TYPE OF SYSTEM _L,,,�eptic 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): proximate age of all components,date installed(if known)and source of information-. Were sewage odors-detect ed wh en arrrvmg at the site(yes or no 6 - Page 7 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 'nl �y A Owne Date of Inspection: 562 3 O/ BUILDING SEWER(locate on site plan) Depth below grade: Materials of constriction: -cast iron _40 PVC ._other(explain):_ Distance from private water supply well or suction line: ` 4 `? ' Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:,/- (locate on site plan) Depth below.grade: P, Material of construction: vconcrete_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) QQ � � Dimensions: O . X(.o'`K S" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffler Scum thicknes Distance from top,of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle; ' How were dimensions determined: Comments(on pumping recommend tions, inlet and outlet tee or baffle condition, structural integrity, liquid levels s related to outlet invert, evidence of leakage,etc.) le GREASE TRAP�J��--Flocate on.site plan) Depth below grade: Material _ 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: f 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: A14 Owne Date of Inspection: TIGHT or HOLDING TANEA4-4tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete .metal fiberglass_polyethylene__other(expla.in): 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: t/(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distributions equal,any evidence of solids carryover, any evidence of akage into or o t of box,etc.): PUMP CHAMBER: /yb70ocate 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 r Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) . Property Address: Owne Date of Inspection: I SOIL ABSORPTION SYSTEM (SAS): locate on site plan,excavation not required) If SAS not located explain why: . - ✓leaching:pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,.dimensions: overflow cesspool,number: innovative/alternative system "Type/name of technology: . Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil; condition of vegetation, I •-26 10WLe- Cie AeuL 45o ,p o'1 62A 65Le, p � 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 or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: 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.): 9 Page 10.of 1] OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE'DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ��,(/� Own 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. 3 Vv" -39 CR 10 s Page I 1 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued). .Property Address: Owne Date of Inspection: =6=2 3/p SITE EXAM Slope Surface water F Check cellar Shallow wells Estimated depth to ground water Z 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: T Checked with local excavators, installers—(attach documentation) Accessed USGS database'-explain: You must describe how you established the high groundwater elevation: - Imdew 2W 11 2 N0.15....... sco Finc 3.0.....0.0....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Diiipu!ml Work.6 Towitrurtion Vamit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: 97 Swallow Hill Dr Cummaquid Deb Eldridge°Ca"°11 'address or lot No. ......................_.......................................................................... ----------------------••-•------------•--•••-••---•••-•--•----••----•-..................-........ Owner Address •Robnson..._Setz- --- evi .........._ P-Q_.__._8ox._.1Il89----Genterui-lle........................ Installer Address Type of Building Size Lot............................Sq. feet .a Dwelling— No. of Bedrooms._-_--_--_3__________________________ ----Expansion Attic ( ) Garbage Grinder (no) aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Otherfixtures ------------ ------------ ----------------- _--------------------------------------- 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. I----------------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.._--_-.--__-.__--_---_. --------------------------------------------------------------------------------•-•------------••----........-------------•-------.......................... ODescription of Soil............sand................................................................................................................................................. x w UNature of Repairs or Alterations—Answer when applicable.....i.nstall new lines and.._d-box Agreement: The undersigned agrees-to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issu by the board o ealth. l �. Signed .... ---- ---/`/DV Application.Approved - ------.. ........ ------------------------------ -------------------- ------_-7/1.9�7_--------------------- Dace Application Disapproved for the following reasons: ................................................................ ........ .......__........................... ...................... ...... .... ..... .... ........................................_._... . --------------------------------W. S Dace a Permit No. ............. �.�,Q ` Issued .. ................ Dace THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of (fontlaliance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( x ) VIERobinson SenIw i C----Serxrice---- ------- ------ ----------------- -- ---------._.._---------------------_._..-------------------------------------- _ at 97.-. Swallow Hill Dr.... Cummaquid - - - ------------------------- ---------------------- ---------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. _---------___..____...---...._....------ dated . _........._ --------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE .... --------------------- --------- ------ Inspector —.� ----' - > THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTHY ^ 0 fir 26 TOWN OF BARNSTABLE 30.00 No......................... FEE...................••... W.0 R�obinsja...SPn�ir..__S�r4r�c�A------------------------ ................................ Permission is hereby granted....-_-.._i_r..._..- . to Construct ( ) or Repair (x ) an Individual Sewage Disposal System 97 Swallow Hill Dr ... ttlti�li�g13)'d.--•---. -at No. •. Street q as shown on the application for Disposal Works Construction Permit No...r Uh f Dated_----.----- --------m...................... DATE............ /•_------ .................................... Board of Health FORM 36508 HOBBS&WARREN.INC.,PUBLISHERS 30.00 THE COMMONWEALTH OF MASSACHUSETTS k BOARD OF HEALTH TOWN OF BARNSTABLE Apphratiun for Divi-puuul Wor1w Towitrnrtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: 97 Swallow Hill Dr Cummaquid --------------------------------- -------------•------•----•---------•----------....----------------•--••-•-••-•--..........--....-- Deb Eldridg,eocation-Address or lot No. ......................_.......................................................................... •-•------•------•--•---•------.....----.....--•----•----..._..-----••-•••-•...------......•------- owner Address a .......�'�--El.RQbinscn-•Sentic__Se�v�c� Pin' ?3tax...�_�2f�g...(_entAr:ri_LlP........................ Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms----------- -------------------------------Expansion Attic ( ) Garbage Grinder (no) aOther—Type 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 ( ) al Percolation Test Results Performed by.......................................................................... Date........................................ a 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........................ �+ •-----------------------------•-----------------------------------------------------......--•-------........................................................ 0 Description of Soil............s`knd.................................................................. V --••-------•----------------------------------•-----••-•-----•---------------------•----....•-•------•---------•.....--------•------ •-------------•-----•--•-----.............................. W -- ---------- -- -------- -- ------ --------- ------------ install new lines and d--box U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ..-••----•--••-------------------------------••------------•-•-•--••----------------------------•---•-----••--------------------------•-----•---•-•----------•--------------•-----------............---• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b ueXbyhard o ealth. Signed . -_---� -----. . .. ... ... .... f,. Application.Approved ........................ _... _.... - ! /Dme Application Disapproved for the following reasons- ----------------------------------------------------------------------------------------------------------------------------------- ---------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------ --------------------------------------- Dare Permit No. � .5 � n.... �................. Issued -----------------. Dare �; t ..s r Commonwealth of Massachusetts Executive Office of Environmental Affairs `� Department of &r Environmental Protection r G Weld F. Id �may, xe .. . vernor Argso Paul Celluccl "Dsvld B.Struhs Lt.Goarnor commWlornr SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION 97 Swallow Hill Road Property Address: Cummaquid, MA AddressofOwner. Swallow Hill Trust Date of Inspection: (If different) Name of Inspector. 9W.2�,—9&o b i n s o n SR Company Name,Address and Telephone Number. ( 5 0 8 ) 7 7 5-8 7 7 6 W.E. Robinson Septic Service P.O. Box 1089 Centerville MA CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: I /Passes — Conditionally Passes Needs Further Evaluation By the Local Approving Authority — Fails C / Inspector's Signature: i 1 Date.- The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. , The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A,B, C,or D: A) SYSTEM PASSES: �. I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. BJ STEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes won IndicLte ,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not) The septic tank is metal,cracked, structurally unsound, shows substantial infiltration or enfiltration,or tank failure is nt. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (rev /03/95) I One Winter Street • Boston,Massachusetts 02108 • FAX(617)SWI D49 • Tekphons(617)292-5500 iAJ Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(oontinued) Property Address: 97 Swallow Hill Rd. , Cummaquid Owner. Swallow Hill Trust Date of Inspection: 9-2 3-9 6 B]SYSTEM CONDITIONALLY PASSES(continued) 4 Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed CJ THER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the. public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2 SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis 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 few than 5 ppm. 3) O ER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(oontinued) Property Address: 97 Swallow Hill Rd. , Cummaquid Owner. Swallow Hill Trust Date of Inspeotion:.9—2 3—9 6 DI YSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due,to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. EI LARGE STEM FAILS: The fo wing criteria apply to large systems in addition to the criteria above The m serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health d safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a public water supply well) The owner or rator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements o 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST 7 w Hill' Rd Cumma uid Property Addlross: 9 Swallow 1. . , q Owner. Swallow Hill Trust Date of Inspection 9—2 3—9 6 Check if the following have been done: —L,1!rnmping information was requested of the owner,occupant,and Board of Health. _L4 one of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. built plans have been obtained and examined. Note if they are not available with N/A. facility or dwelling was inspected for signs of sewage back-up. (/The system does not receive non-sanitary or industrial waste flow jhe site was inspected for signs of breakout: _Ze:::/e m components,.excluding the Soil Absorption System, have been located on the site. septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction, dimensions,depth of liquid,depth of sludge, depth of scum. size and location of the Soil Absorption System on the site has been determined based on existing information or �roximated by non-intrusive methods. t _The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. f (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 97 Swallow Hill. Rd. , Cummaquid Owner. Swallow Hill Trust Date of Inspection: 9-2 3-9.6 FLOW CONDITIONS RESIDENTIAL: Design flow: ons Number of bedrooms:. Number of current residents: 0 Garbage grinder(yes or no):_,d,C) Laundry connected to system(yes or no): 5 Seasonal use(yes or no):d_D Water meter readings, if available: 9 4-9 5 34, 000 gallons 95-96 42 , 000 gallons Last date of occupancy: COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow:_gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)_,d_e-') If yes,volume pumped: gallons Reason for pumping: TYPE OF STEM ptic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records, if any) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source of information: ,� x $ Sewage odors detected when arriving at the site: (yes or no) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) propertyAddeess: 97 Swallow Hill Rd. , Cummaquid Owner. Swallow Hill Trust Date of Inspection: 9-2 3-9 6 SEPTIC TANK: (locate on site plan) Depth below grade:f6. � Material of construction: Lo4ticrete_metal_FRP_other(explain) c � ► Dimensions: x ludge depth: C) $Distance from top— of sludge to bottom of outlet tee or baffler Scum thickness: 0 ti 4 Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or battles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) /.� + A- Jt &04 S" ye Q: Ai�ltJ a7o �(J%� O E TRAP:_ (locate site plan) Depth bel w grade: i o construction: concrete_metal_FRP—other(explain) ess: m top of scum to top of outlet tee or baffle: m bottom of scum to bottom of outlet tee or baffle: Comments: (recommen on for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of etc.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) propertyAddr+ws: 97 Swallow Hill Rd. , Cummaquid owner. Swallow Hill Trust Date of Inspection: 9—2 3-9 6 TIGHT OR HOLDING TANK:_ ( on site plan) Depth low grade: Material construction:°concrete_metal_FRP_other(e:plam) Dimmudo Capacity: ons Design flo gallons/day Alarm 1 Comments: (condition of et tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal,evidence of solids carryover, evidence of leakage into or out of box,etc.) PUMP BER:_ (locate on ite plan) Pumps in rking order:(yes or no) Commen (note cc oa of pump chamber,condition of pumps and appurtenances,etc.) (revised 11/03/95) 7 • U SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 97,Swallow Hill' Rd. , Cummaquid Owner. Swallow Hill Trust Date of IInspeotion: 9—2 3—9 6 SOIL ABSORPTION SYSTEM(SAS): (locate on sits plan, if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type. leaching pits,number:_ leaching chambers,number:_ leaching galleries,number: leaching trenches, number,length: leaching fields,number,dimensions: overflow cesspool,number: Comments: (note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetationetc.)- 42 CS O C R L, f 2-, . C IS:_ (locate site plan) Number and configuration: L,Dlept�h. p of liquid to inlet invert: solids layer: scum layer: no of cesspool: Ma of construction: Indicatio of groundwater: ow(cesspool must be pumped as part of inspection) Comments: note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) PRIVY: (locate on site ) Materials of oo n: Dimensions: Depth of solids: Comments:(n condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.) (revised 11/03/95) g SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) PnopertyAddress: 97 Swallow Hill Rd. , Cummaquid Owner. Swallow Hill Trust Date of Inspection 9—2 3—9 6 SICMH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' va e �r \ 's L l) 1�C`X DEPTH TO GROUNDWATER Depth to groundwater: 2--r feet method of determination or approximation: (revised 11/03/95) 9 Town of Barnstable = Department of Health, Safety, and Environmental Service _ 6' Health DivisionS' S � 367 Main Street,Hyannis MA 02601 - 1 ORice: 508-790-6265 Thomas A McKean FAX 508-775-3344 Director of Public Health June 1, 1995 R. Clifford Mihail 97 Swallow Hill ROad/Claire Lane Barnstable, MA 02630 Dear Mr. Mihail: The septic system owned by you located at 97 Swallow Hill Road, Barnstable was inspected on May 11, 1995 by Peter Sullivan/Joseph Macomber Massachusetts licensed septic inspectors. The inspection of your septic system showed that your system has passed under the guidelines of 1995 TITLE 5 (310 CMR 15.00), however, the following should be corrected. • Broken distribution bog cover. • Outlet tee in septic tank needs replacement. • Septic tank needs to be pumped. Please telephone Health Inspector Edward Barry'at 790-6265 within thirty (30) days to discuss your intentions in regards to rectifying these deficiencies. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health a � ASSESSORS MAP NO: 33 C� PARCEL NO: 7/ j r Town of Barnstable • Department of Health, Safety, and Environmental Services RAMSPASM 6'9- � Health Division 367 Main Street, y Hyannis MA 02601 Office: 508-790-6265 Thomas A.McKean FAX: 508-775-3344 Director of Public Health June 1, 1995 R. Clifford Mihail 97 Swallow Hill Road/Claire Lane Barnstable, MA 02630 O , The septic system owned by you located at 97 Swallow Hill Road, Barnstable was inspected on May 11, 1995 by Peter Sullivan/Joseph Macomber Massachusetts licensed septic inspectors. The inspection of your septic system showed that your system has passed under the guidelines of 1995 TITLE 5 (310 CMR 15.00), however, the following be corrected. Slao�i 1 • Broken distribution box cover. • Outlet tee in septic tank needs replacement. • Septic tank needs to be pumped. ��z 1 z la,�p k�.e �-i-�.11�it d�s�c 4�r --� � � 9° 6�6 s c,J�E>�(� o �Irecfedtobring t e se ' nce i hi 30 da s of receipt 11 o L) ,r � 5 iA ,-e s , aggrieve y any ore 't ma a eal to ,���� , any court of com ep tent jurisdiction as provided for by the la PER ORDER OF THE B ARD OF HEALTH 0 Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health [Installer letter], TO: j a� G�G� (Date.,!!� ry�4 ) 9-7 s�glltJ ICvrb(�e MA ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE, TITLE 5. The septic system owned by you located at 7 7 ,���„c 1�,�( � was inspected on I1 Ir6 by 7sacr„k Massachusetts licensed septic inspector--57 . The inspection of your septic system showed that your system r the guidelines of 1995 TIT E 5 (310 CMR 15.00)a : � N�2f+ C nb A d'er 4eQ i n _s n - -� ��c�S r e UAw e. You are Jirect54jo hire a lice ed Town of Barnstable septic s m installe�r�t bmit a sketc a m a pro ed ystem to o n of Ba ab He ivi 'o ce (T all, 3 Street yan ' that w' 1 bt.,RTitle a se is stem into complia e wi 10 C .00, The at nvironme al 5 within (14) fourteen days r eipt of this notice. You are directed to bring the septic system into compliance within thirty (30) days of receipt.of this order letter. You fu irected main in t ste by hirin ' ensed septa ler to mp t septic s to prev t charge o se or efflue t i a buildings, o the s ace of the ground, or i o surface wat Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the.laws of the Commonwealth. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health Town of Barnstable .a, t Town of Barnstable i Department of Health, Safety, and Environmental Services MAWHealth Division 367 Main Street,Hyannis MA 02601 Installer ice. 65 Thomas A.McKean FAX: 508-775-3344 Director of Public Health TO: C ai re- (Date) Mftj Be rnshn/cce- MA ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE, TITLE 5. T ekseptic system owned by you located at 7-7 "` Cif Roa , Stkqq—iu the village of 5 14 66, was inspected on /4--, rys by mc,�"4 Mfg- sal/v, A Massachusetts licensed septic inspectors P The inspection of your septic system showed that your system has iW under the guidelines of 1995 TITLE 5 (310 CMR 15.00)od . l-Aviever U-It -r(Iz�f- -Z)Cn e��`L r c= LgF4ff[11 1 ' &44-fit-' -k', Ire ':6eQfi a `1 IG i)ee.4S WiW4� You are directed to hire a licensed Town of Barnstable septic system installer to 41iiWlPh p bring the septic system into compliance with 310 CMR 15.00, The State Environmental Code, Title 5 within(14)fourteen days of receipt of this notice. , Y letter. tg P e Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., C.H.O.. _ Agent of the Board of Health Town of Barnstable title 5(1) TOWN OF BARNSTABLE t LOCATION SEWAGE # VILLAGE ASSESSOR'S MAP & LOT . INSTALLER'S NAME PHONE-NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type)~ (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No i 1 m � j t7 7 5 44/A G,L 0 uJ 4 D AT E: 5-1il_.L2�--- PROPERTY ADDRESS: 97 Swallow Hill ��__ Barnstable,Mass. 02630 ------------------------ On the above date, I inspected the septic system at the above address. This system consists of the following: A. 1 -1000 gallon tank. B. 1 -distribution box. C. 1 -1000 gallon leach pit. Based on my Inspection, I certify the* following conditions: A. This is a title five septic system. ( 78 Code ) B. Several repairs must be made to the septic system C. All repairs must be made for the safety and welfare of others. D. The septic system w'i.11 be. in proper working order once all repairs are done and the septic tank is pumped. SIGNATURE: Name: J.P.Macomber_J Company:J_P.Macomber & Son Inc. j Address:_ ,Box 66 ------------------ ; Centerville.-112632 Phone: 508-7.75-3338__--___ THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY • JOSEPH P. MACOMBER & SON, INC. raw- - - Tan ks-Cesspools-LeachfIelds Pumped & Installed Town Sewer Connections P.O. Box 66 Centerville, MA 02632-0066 775.3338 775.6412 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIOX- FORM Address property L) Owner 's name., me ��� ` L� "}a� Date of Inspection XP(ZIL Z9, \995 At 1i�,Ig JUP� PART A CHECKLIST Check if the following have been done: 4 • v Pumping- information was requested of the owner occupant and •Boa Health., ' � rd of L/ ' None , of:'the' system components have been ks pumped for at least two we and the system has been receiving normal flow rates during that . S period.;... Large volumes of water have not been introduced into the system -recently or as part of this inspection. NIA As built plans have been obtained and ex available with N/A. amined. Note if they are not � The facilit p g y .or dwelling was inspected for signs of sewage back-up. The site was inspected for signs of breakout. : All system components, excluding the SAS, have been located o n the . The septic tank manholes were uncovered, opened, and the 'interior of the septic tank was inspected for condition of baffles ortees material of construction, dimensions, depth of liquid, . depth of sludge,., depth of scum. The size ' and location of the SAS on the s ' on existin site has been i determined g. nformation or a z'mined based approximated by non-intrusive methods. The facility owner (and occupants, if different from own provided with information on the proper maintenance of SSDS.Were �v w��., nr 2..{ U F �•E c-a ti-�.�1�N�,4�1 p N s 1, ,. C'C5 r`�l M E t tJ CUT1 �.1 1�9 C o ( 30 �`T-AL_ (, $� 2 3. 1� �ak. `ls.c�--QS• ''1� 't3� �c�i�ii2� .. � W �i P d ►'1.)6 ,�ilL,,p Cal K c TZ.� " �'• l� u E�..t' �2t5c raY 'Use - 6�► IINC� L�.piU G IT D(FF(CULT TU ASSS5 T�-t i=. FU>aCT1oN LIT C)r T�AE OVE�AlL 5�/Si�i� �1or• .Fia,�� ic�. Tt-tt5 5�1s T wl S Ou p o bTN E C o tU S1TZ-U o GO AS a �� 'SUBSURFACE 8 SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART 8 SYSTEM INFORMATION ,. FLAW CONDITIONS If residential I' number' of bedrooms number of. current, .residents garbage grinder yes or no, �• laundry connected to system, yes or no seasonal use, yes or no , If nonresidential, calculated flow: j1-��S IS 1-41 G E-( t�s� _D fl �� ... . ,.. KkCrrL.c J Tr Tmeec-, is LA�� Water ... ��. tee meter :readings, if available 93/9 2 S'� OoQ C7h�c.o G98 6P D 39 OHO �S GO,LLO — Last date of- occu anc y GENERAL,. INFORMATION Pumping records and urce of information: Tp , System pumped as part of inspection,if .yes, volume pumped yes or no Reason. for. pumping: - ' r Iya of s(�stem ( . Septi"C' tank/distributi Single cesspool °n box/soil absorption system Overflow., cesspool _ Privy, Shared system (yes or no records, if any) (if yes, - attach previous inspection . Other (explain) Approximate age of all, on compents. Date installed,, if known. Source C � Sewage odors detected when arrivingat the ' site, yes or no • . • 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK: (locate on. site plan) depth below.-.grade: TZ3 1Z material of construction: _concrete metal FRP other(explain) dimensions:" ... _S K sludge depth .' distance from top of sludge to bottom of outlet tee or baffle scum ,thicknass distance . from top of scum to top of outlet tee or baffle distance from bottom of scum to bottom of outlet tee or baffle. Comments : (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, recommendations for repairs, etc. ) L t2 C P i . l ca I?Ev _ vL u tk LA DISTRIBUTION _.BOX.:. . (locate on site.,.plan). depth of •liquid level above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for re airs, etc. ) 42by EZ 1.f52C>46" . -Boy, L C)OV-S X ti C1J CL � Q2 12� �EPu4CcctiC� PUMP 'CHAMBER.. (locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs,etc. ) ------------- �� ' 1Q SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION Continued SOIL •ABSORPTION SYSTEM (SAS) :�_ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: i Type leaching pits and number _ ► • Pc'T 1� GAS v(US leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number, Comments: (note condition of soil, signs of hydraulic failure, level of ponding, . condition of • vegetation, recommendations for maintenance or repairs,etc. ) kA _.. ... .CES SPOOLS•.;(locate on site. plan) : - Y number and configuration C� ►..l L, depth-top- of liquid to inlet invert depth of solids layer . depth of scum layer r dimensions of .cesspool materials of. .construction j Ind ' ,' tion' of groundwater. .knflow •(0�sspool zust be pumped as .art of inspection) ........... : .. Comments: (note condition of soil, signs of hydraulic failure, level 'of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) , • i PRIVY: (locate on site plan) materials of. construction © N, dimensions depth of solids Comments: 1 j (note condition .of soil, signs of hydraulic failure, - le J 4 condition of vegetation recommendations vel of .pondin for maintenance or re airs etc.) p �. �rac�,00 D • 11 SUBSURFACE ,SEWAGE DISPOSAL SYSTEM INSPECTION 4ORM PART B SYSTEM INFORMATION continued SKETC13. OF',SEWAGE DISPOSAL SYSTEM: - include tins to at least two permanent references landmarks `or benchmarks locate all wells within ;00' DEPTN TO..IROUNDWATER depth to• groundwater RE Lc��"U S A�S method of determination or approximation: tD F S \d, l4A kZ LAN 0 N tC Q�U 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate , es no or not determined Y N Y ( or ND) . Describe basis of determination in all instances. If "not determined", explain why notj o Backup of .sewage into facility? Discharge or ponding of effluent to the surface surface waters? of the ground or ►�'O Static. liquid level in the distribution box above outlet invert? Liquid .depth in cesspool <6" below invert or available volume< flow? 1/2 day Required pumping 4 times or more in the ? —» last year. number !of times pumped Septic tank is metal? cracked? structurally infiltration? substantial exfiltration? tankunsoun failure imminent?al Is any. portion of the SAS, cesspool or privy: below the high groundwater elevation? �O within. °'50' feet of a surface wa ter? within • 100 feet of a surface water supply tributary water supply? P Y or ributary to a surface Kio within :a Zone I of ab p•u_.l.ic- well? within 50 feet of a borderin (cesspools and g Vegetated wetland or salt marsh privies only, not the SAS) ? within 50 feet of a private " P to water supply well? 0 less than 100' feet but reatert han Supply .wel.l with no acceptable Water 5quality o feet fanalys s?rom Valf water' has been .analyzed to be acceptable attach co r analysis for coliform bacteria, volatile Qrganic compounds, ammonia and nitrate nitrogen. g o. SUBSURFACE SEWAGE DISPOSAL INSPECTION.FORM PART D CERTIFICATION Inspector : Peter Sullivan PE Location : 97 Swallow Hill Road,Barnstable Date : April29,1995 Certification Statement I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate,and complete as of the time of inspection. The inspection was performed and any recommendations. regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and maintenance of on-site sewage disposal systems. I have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR, 15.303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. Please note the summary of recommendations as presented in this form. J, Very trul yours o Peter Sullivan PE Distribution: Original to system owner Buyer Board of Heath OF PETER { SUUIVAR 110- 29733 At�t4�� ' No............�':- Fims....ll� THE COMMONWEALTH OF MASSACHUSETTS BOAR DF H EA T /3.I�.�'rr.i� ��'�rt ...------ V�U-1?--......OF..... :.. ,6 , firation for_Dispasal parks Tonstrnrtinn rani# / 7 Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: 1...... -� 5�,V OW 100f4v&...............................................................�.--' ' ........... L ' n- ddress r , N _ M� .. ..... �....._ ...�..............��' -1...��.� a................--•-- ..:��� ®.� may- ... -- �C '�..................... Installer �-•.�C�..�-��'.. ._`!..!_...... =..�... Address Type of Building r Size Lot............................Sq. feet Dwelling—No. of Bedrooms................. . ..... ...............Expansion tic (/�J Garbage Grinder (♦(� p•, Other—Type of Building Q-_Fi � o. of persons_________ _________________ Showers ( ) — Cafeteria ( ) Q'' Other fixtures ..__.._.__ W Design Flow............... �........___........gallons per persorefpy. Tota�aily flow.......... ..................gallons. WSeptic Tank—Liquid capacit/MNallons Length... ........... Width. ..._.!t..__ Diameter................ Depth................ Disposal Trench—N ........... ..... Wi tji___ ._ Total Length ... Total leaching area.._... __. sq. ft. x p y------- Seepage Pit No. .......... iameter. ..+:� .... Depth below ir}let•.�----........ Total leaching ar;�a ..__._sq. ft: Z Other Distribution box (i; � Dosing tank ( ) a /0 C-' d . / Percolation Test Res ul Performed by--------------------•------------........ -s�•.....•-•-•_.... Date.................................... _-. ,tea Test Pit No. 1._;;k_.minutes per inch Depth of Test Pit.. ..... Depth to ground watehay _i� ® GT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ x me ------------------------------�---•---•---....•- ------•- ......................................................... 0 Description of Soil............ -------•- ----- _ ........................ .. -••--- pua = j��•-•-----••..............•. -- - ......- --- ................................................................... U Nature of Repairs or Alterations—Answer when applicable...................................................•._..............._.__..._____._.........__. --------------------•------•----•-••--•---•--•----•----•----------------------------...............•---.......-------------•----------............................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Co e—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be * s t eard of ealth. . ...Signed--- ......s�....-- --•-............................................. .. ...... �� .. Date Application Approved By.... Date Application Disapproved for the following reasons---------------•-------••----------------------................................................................. ....----•-•---•-----•--------•..................••-•-•-------•-•---------....---•----------•-------•---•----------------------------------------------------------------------------------••-•---------- j Date Permit No........................................................ Issued----11--3d 7 7 Date y No. ..._ '" . ,`�` Fps... + «"............. THE COMMONWEALTH OF MASSACHUSETTS BOARD—OF HEALTH OF......------ -.--_--•------••-------- v r Ali' firation for Diipuaal Workfi Tomitrurtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ............ - --- - OIL. 0j......................... -----•-• -----------........_ .---•------- .................... Loc�at'on-,,, dd ess - /� r _ 0 f �� Q� Address a .....-•----•-------•--...----•-•.`--------•--••---••-•-•-•..... ......•--•----•-•- r ..... ......... ....•-.......' !_..c4.................................... Installer Address Type of Building Size Lot----------------------------Sq. /,feet Dwelling—No. of Bedrooms.'... ................. Expansion tic � Garbage Grinder (K�P '4 Other—Type T e of Buildin JY p•� yp g�:_.._...:.`K'�'1....._ No. of persons_.___..._;:._:............. Showers ( ) — Cafeteria ( ) p"' Other fix tur W el s Design Flow.................s_....... ._......_.._gallons per perso per ay. Tota flow................. r_Z�.____........gallons. WSeptic Tank—Liquid capacity/ ?gallons Length..-"--- Widt ."_... Diameter................ Depth................ x Disposal Trench—No-------------_--_-- Width_.,....f. ._...._. Total Length......... _._...... Total leaching area... sq. ft. Seepage Pit No____________ ______ Diameter C�..:__ ..._. Depth below inlet_.._..I........ Total leaching area �._sq. ft. Z Other Distribution box ( ) Dosing tank ( ) p c I4 Percolation Test.ResuIxs Performed by---------------.... ----------------------•---------------------------- Date_----•---•--._..._..-----------•-------- ,-4 Test Pit No. 1................mmutes per inch Depth of Test Pit_/_V: .... Depth to ground wate -------'�� GT., Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ix ......... ....................................... /d1✓ O Description of Soil I •-----------••-••- .-------------------------- - /Scr �- Gam _ �� .------ . W --------------------------------------`-��-`-`` !` �1_r.----��....'............._�. r✓.G.��.....----- UNature of Repairs or Alterations—Answer when applicable............................................................................................... �.R ------------------------------------•-----...-----------------------------------------------------------------------=-------------•---------------------............................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITT-2 5 of the State Sanitary Co —The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee i u th of iealth. Signed. •..•• .... -----•.......--•-•-•--••--•--•-.C am/ -- a` !� Application Approved By..... � '' •--. •.- ''". « "'% --/�------ Date Application Disapproved for the following reasons---------------------•------------------------------------------------•---•-•-•......--•••...................... .............................................................•-----•-•-•---------•...............••---..._..._......•-•••-•-•••••-••--••--•••--•-••••••-••-•••-•••-•-•••-•--•-•----- ......---....... Date Permit No. = Issued------------------------ _ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF� HEALTH ............ � .... ......OF............41a .. . ........................................ 1; rtifiratr taurr I ' F t he Individu 1 Sew a e Disposal System constructed ( ) or Repaired ( ) . by.... --_-.•. •---- ----&�4 -t_-•-••• . �JJ/ ......................................;& ... at ......................................................... ------... has been installed in accordance with the provisions of T ; 5 iTFitate Sanitary E & e in the application for,:V posal Works Construction-Permit No... .__.._•. dated-......... ........ ...................... THE ISSUANCE OF THIS CERTIFICATE SHALL;,NOT BE CONSTRUE® AS"A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY.'` DATE..................................................................•---- Inspector -::;---------------=-- .................................. THE COMMONWEALTH OF MASSACHUSETTS rBOARD O HEALTH ............................................O F................................-.........................:.......................... No.... FEE.:._..:.. BiapLw ti rr tit Perm> on i ereby granted -- -- ----•--•-••• ••• ...... ... .•••-• •- to Con c it � v1d .' e DIs S )IX "l 47 atNo... > •--- - --.----•--------- -- --•_.. . . ----• -•--•••. •-••-••• •-•-•_. Street as shown on the applica ion for Disposal Works Construction Per Board of Health,,. DATE-- -/ .../ = .... -r: FORM 1255 HOBES'& WARREN, INC.. PUBLISHERS - LPQE C�O ����►,110M a 0 MACLEAN CONSTRUCTION 1 r 1 Hunt i it on Ave, •`' ' FG � Z SOUTH YARMOUTH,MASS.02664 ` •% f TORS AN 0 OFFICE: 394-6551 HOME: 771-1415 gSSOCIA10 Oct . 12 , 1977 Note: The radius of impervious material changed from 25' to 10' per C.M.S Associates. MacLean Construction Corp. i� `• • I � ``���.A � ..44. may/) f//' i. o• Tct.o ,�svO�/• rrsl�Z�' p/� ,�C/�ltr�eYE© C-��At7F-."-. >zl /-06 60 I /f // �.s,i�r / �'/N1.5/✓$O Lei ept-;> E �S '� •n°' OQ,OYC.�.N yo _ .Ct ' t"'j..� 3tiy=mod ,ArT,C M ' /•Yv�' caAL.Gon/5 7- WAIr /N!/E/'��'t t�� /�r�'� , : ��.,,s -/fZ �,��•�• GA.E'QAG.r=Z - /'t 'b ul -I E .s y,5 T`.4=All ��/ ,-4_G 1 21_7 C:3f";IQ41G24?/ lov Ar'�', C1>0z' PLAN SHOWING P R 0 P 0 SE D C O.N_ STRUCT10N L 0 C A T t 0 FOR . /lf' i ',G ,, �v�` c ,G► .�'t r "' i':.y `r.�r �' c' r' A P Fi R O 1/ E C} 1977 SCALE : '`' `' � DATE: BOARD OF HEALTH rR E F E R E NC E -• r 1Gr: :sr3 L O /10////77 -5 f�<::),k �'✓ •.� �c �:.C,�J' �' . !` 0 ATE A G E N T *S,' , �� .7'.:.:.~i:.. '� ri i r �,.r.f.t '�s[�t� �r. .c' �._� ,• �� :,.�! �' - .art =� �• ` ASSOC i A T E S! I N C a � ►f . rAH`° :' ,cy/: REGISTERED ENGINEERS & LAND SURVEYORS MID-CAPE OFFICE LUILDING -- 1265 ROUTE 28 SOUTH YAR ,, UUTh, (MASS. 026564 r..T. rrzl L� ' M S'�C2�ln e�NtY�`2 �� r.� 7: i Cp t _ S TO -7 � I � i I i C�_J PO N� i , , .p t , i + n JL Aw a V ., r �/�l • JLLU;, LU , co '. L � N go aa • , , f � x + 7 UL -47 40 z , - r -� , .Y .D fi + Tu 1 7 Kw�'k i 4 b Y � x DATE:. 17 4f SCALE' DRAWING#: