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HomeMy WebLinkAbout0171 TONELA LANE - Health 171 Tonela Lane Barnstable.. P A 336 025 ' i k li Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 171 Tonela Ln. Property Address CID Richards Owner's Name Barnstable MA 02630 8/11/16 9: City/Town State. Zip Code Date of Inspection Inspection results must be submitted on this form..Inspection forms may not be altered in any 4'. way. A. General Information 1. Inspector: Frank Nunes III ' Name of Inspector saa Company Name Box 841 ' Company Address East Falmouth :MA = 02536 City/Town State Zip Code 508.272.6433 Telephone Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 8/11/16 Inspector's ignature 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. y ****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. 171 Tonela Ln.•03(08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 . 4 .m . . Y . �b vs Commonwealth of Massachusetts Title 5 Official Inspection Fora' Subsurface Sewage Dispose'System Form. Not,for Voluntary ryAssessman is M , 171 Tonela Ln: Property Address Richards Owner's Name Barnstable MA 02630 '' 8/11/16 , Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure,criteria not evaluated are indicated below. Comments: Pumping suggested every 3 yrs to prolong the life of the system 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 iless than 20 years old,is available. ND Explain: n/a ❑ 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 171 Tonela Ln.•03/08 "Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 171 Tonela Ln. Property Address Richards Owner's Name Barnstable MA 02630 8/11/16 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ distribution box is leveled or replaced ND Explain: n/a ❑ 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: n/a 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 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. M Tonela Ln.•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments < 171 Tonela Ln. Property Address Richards Owner's Name Barnstable MA 02630 - 8/11/16 CitylTown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: n/a D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® 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 Y2 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. 171 Tonela Ln.•03/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 171 Tonela Ln. Property Address Richards Owner's Name Barnstable MA 02630 8/11/16 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] The system is a cesspool serving a facility with a design flow of 2000 d- Y p 9 tY 9 9P ❑ ® 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The, system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. 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 shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate - regional office.of the Department. 171 Tonela Ln.•03f08 Title 5 Official Inspection forth:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 171 Tonela Ln. Property Address Richards Owners Name Barnstable MA 02630 8/11/16 CityTrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided b the owner, occupant, or Board of Health P 9 p Y P ❑ ® Were any of the system components pumped out in the previous two weeks? F ® ❑ 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? ® ❑ Were the septic tank manholes uncovered, opened; and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 171 Tonela Ln.•03108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 171 Tonela Ln. Property Address Richards Owner's Name Barnstable MA 02630 - .8/11/16 Citylrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: ` Number of bedrooms(design): 3 Number of bedrooms (actual): `. 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ® .Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date Commercial/Industrial Flow Conditions: Type of Establishment:y ; n/aV Design flow(based on 310 CMR 15.203): s Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? • ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No t Water meter readings, if available: Last date of occupancy/use: Date Other(describe): n/a 171 Tonela Ln.•03/08 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 171 Tonela Ln. Property Address Richards Owner's Name Barnstable MA 02630 8/11/16 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: 2002 per owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Septic tank to 2 pits Approximate age of all components, date installed (if known)and source of information: New septic tank and leach pit 1992 per BOH record. Block pit 1966 per age of home Were sewage odors detected when arriving at the site? ❑ Yes ® No 171 Tonela Ln.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , y 171 Tonela Ln. Property Address Richards Owner's Name Barnstable MA 02630 8/11/16 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): -Depth below grade: 2'feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): >10' Distance from private water supply well or suction line- feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) Outlet cover raised If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 1000g 4" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle >12 Scum thickness trace-1/2" ,21- Distance from top of scum to top of outlet tee or baffle >2 Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Measured 171 Tonela Ln.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , ' 171 Tonela Ln. Property Address Richards Owner's Name Barnstable MA 02630 8/11/16 City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping suggested every 3 yrs to prolong the life of the system Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): n/a Dimensions: Scum thickness. Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): n/a Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑ fiberglass. ❑ polyethylene ❑ other(explain): n/a 171 Tonela L:i.•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 171 Tonela Ln. Property Address Richards Owner's Name Barnstable MA 02630 8/11/16 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): n/a Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan):, r Depth of liquid level above outlet invert No d-box 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 ❑ No Alarms in working order: ❑ Yes ❑ No 171 Tonela Ln.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form, Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 171 Tonela Ln. Property Address Richards Owners Name Barnstable MA -02630 8/11/16 CitylTown State Zip Code Date of Inspection D. System Information (cont.) - Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): n/a Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit to overflow pit. Pit"B" is of block construction, 4'x6', and was the original cesspool, it is full at this time and is equipped with an inlet and outlet T. Pit"C" is of precast construction, it was video inspected and is approximately half full, the pit is<20'from the pool (OK per local BOH agent) 171 Tonela Ln.-03/08 ° Title 5 Official Inspection Form;Subsurface Sewage Disposal System-Page 12 of 15 L o TOWN OF BARNSTABLE LOCATION {'. %-'/�,+ti e_1 a Ly,,.,, SEWAGE # VILLAGE r, ASSESSOR'S MAP & LOT-JJLI 0� ✓ INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LDbO, 9RJ1dw Le,ch I LEACHING FACILITY: (type) each,K_)o �, (size) loon Q A 1 . NO. OF BEDROOMS BUILDER.OR OWNER 3-A ng e s R i ck"p-A s PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by_����,'s l r ,�k ha)e l uuc . AlC/►beAsv�.me,�'� � 4-r -f- Cc"k r- o*f- Aji*47 QuS G f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M SyO,� 171 Tonela Ln. Property Address Richards Owner's Name Barnstable MA 02630 8/11/16 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): n/a 171 Tonela Ln.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 171 Tonela Ln. Property Address Richards Owner's Name Barnstable MA 02630 8/11/16 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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. 0 � q � c, � � 171 Tonela Ln.•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form , Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 171 Tonela Ln. Property Address Richards Owner's Name Barnstable MA 02630 8/11/16 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: >12 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Per elevation of home 171 Tonela Ln.-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 15 t � •\ COMMONWEALTH OF MASSACHUSETTS -' EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS a f DEPARTMENT OF'DN ONIVIENTALtPROTECTION:LTH.DEPT. REED DE2002 __TOWN vSTABLE H TITLE 5 OFFICIAL INSPECTION FORM;-NOT-FOR.VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM. PART A a. CERTIFICATION , 1 Property Address:_� I �l�r,�)er1 Lug t oz630 3 � ..Owner's Name: Tdti _S�?� ,�i-.ok fz iks p SAP Ow .. - Owner's Address /7/ o tj 2 / v; TT7pft MA Date of Inspection: 112/ ALOM - _ Name of Inspector:(please print) r Tom. (Z Y--,,A! (),"1) Company Name: r�� Mailing Address: .(1_)r, ,;a c�n;-Lj_i_f Gil Gl;e� moo, mA ozq-6� Telephone Number: .So� - 41 7?'=p`/7Z CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the`time of the inspection:The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15 000) "The"system ' Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: �� Date: 5�Z / 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 Iq,000 gpd or greater,the inspector and the system owner shall submit the reporEto 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 1y Page 2 of 11 - tf . OFFICIAL INSPECTION FORM �NOTFOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: /7V Owner:jce c Date of Inspection: .Inspection Summary;_.,Check`A,B,C,D or:E/ALWAYS complete:all of Section D A. System Passes: I have not found any information which indicates that an'yof 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 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 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): 7. broken pipe(s)are replaced obstruction is removed ND explain: 2 ` . Page 3 of l 1 OFFICIAL INSPECTION FORM"NOT FOR VOLUNTARY ASSESSMENTS BSURFACE SEWAGE DISPOSMAYSTEVI-INSPECTION FORM SU PART A , CERTIFICATION(continued) Property Address: �/(�e Owner:�%km.eS /2l mil.cart-cam Date of Inspection: 10 2 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 ofa surface water'supplyor tributary to a surface`water supply: The system has a septic tank and SAS and the SAS is within a Zone l'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 front a private water supply well".Method used to determme'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`eriteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM :NQT-,FOR VOLUNTARY=ASSESSMENTS. SUBSURFACE-SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART A" CERTIFICATION(continued) . Property Address: /7 / To N C'i QAaTj9Tc�.4,Le— MA 02630 .. ._. ... Owner: ;7A.ma,S 27,LcwtoL5 :. ._...... ;._..y Date of Inspection: 12//o a ". ;.; 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 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 V 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 Y Any portion of the SAS,cesspool or privy is below high ground water elevation. .Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water-supply: . _ ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well.. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a.cesspool or privy is less than 100 feet:but greater.than 50 feet from a private water supply well with no acceptable water quality,analysis [This system passes if the well water analysis, performed at a DEP certified laboratory,.for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that fac,ility and the.presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to.this form] (Yes/No)The system fails.I,have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore,the.system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. :.Large Systems:. To be considered a large system the.system must serve 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 wtthm 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 shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 i 1 Page 5 of 11 t -OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE'DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: /7/ Td N Owner: T4—aS Date of Inspection: l2�IoIOZ- Check if the following have been done You must indicate` +es"or no as to each of the following Yes No Pumping information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeks Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection _ Were as built plans of the system obtained and examined?(If they were not available note as VA) _ Was the facility or dwelling inspected for signs of sewage back up� _ Was the site inspected for signs of break out? Were all system components,excluding the SAS, located on site? Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? v _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ' Yes no _ Existing information.For example,a plan at the Board of Health.. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] 5 . Page 6 of 11 r ,OFFICIAL INSPECTION.FORM, .,NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM _INSPECTION FORM PART C SYSTEM INFORMATION Property Address: /71 70N)e t- L.c w-,— Owner• Date of Inspection: FLOW CONDITIONS _. RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual):- 'DESIGN flow'based im 31.0 CMR.15.203(for example: 110 gpd x#of bedrooms). 3�3 t-- t Number of current residents: Z. Does-residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no):.L0[if yes separate inspection required] Laundrysystem inspected es or no : N y P (y ) Seasonal use:(yes or no): No Water meter readings, if available(last 2 years usage(gpd)).` f -- r�eLN,6- Z,�b&, Sump pump(yes or no): NO Last date of occupancy: 12�jo�o Z COMMERCIALFINDUSTRIAL'.; 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: Was system pumped as part of the inspection(yes or no):_ If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic Se — p 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 operatiodand maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): S7VTi�-"T K 1 Gu S Gov l St�l Approximate age of all components,date installed(if known)and source of information: —TA NM $A S 1eeA iN /99Z / C•e-sspoo1 utjK,�� Were sewage odors detected when arriving at the site(yes or no): ti® 6 Page 7 of 1] .OFFICIAL;INSPECTION FORM NOT FOR-VOLUNTARY-ASSESSMENTS .SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ . . ,fi .. .. : . ,-PART.C. _ e. ... .. .. . SYSTEM INFORMATION(continued) Property Address: /7/ Toro ell w. L e_ Owner: �Ka►�C.S i2.iC.har .� r Date of Inspection: 12//a/6z_ BUILDING.SEWER(locate on site plan), - Depth below grade: Materials of construction: )-cast iron 40 PVC_other(explain): Distance from private water supply well or suction line: N//a 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(explam)_ 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: 6'f Distance from top of sludge to bottom of outlet tee or baffle .S F .. Scum thickness:. �. /_... . _ .... Distance from top of scum to toplof outlet tee or baffle: y Distance from bottom of scum to bottom of outlet tee or baffle: < 1 How were dimensions-determined: p-q &b t ?Ow:C- Comments(on-pumping recommendations;inlet and outlet tee or baffle condition,structural integrity,liquid levels = as related to outlet invert,evidence of leakage,etc.): 6rj' GREASE TRAP:_(locate on site plan) .._ _. Depth below grade: 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: 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.l 1 ' OFFICIALINSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS , SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM : PART C41 :. '•SYSTEM INFORMATION(continued) Property Address: /�� 76N e� �n L _ faw�ru�STi�-tote. »'►F� csz63o �..,,_ - Owner: PAyKens 21(,kmt s Date of Inspection: r?_//o/02._ 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: (if present must be opened)(locate on site plan) ..-- Depth of liquid level above outlet invert: 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 . i Page 9 of 11 OFFICIAL'INSPECTION FORM=NOT F-OR VOLUNTARYr�SSESSMENTS ,SUBSURFACE SEWAGE;DISPOSAL SYSTEM.INSPECTION FORM " PART C SYSTEM INFORMATION(continued) Property Address: /7/ -raj e,I c, I3�rn.�asTu,hlln rnr� oZ63o , :,, Owner: 7'*-w,0-5 fZ,`L�4,aWL Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why - TYPe✓ I , eaching 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, etc.): o i CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: _ Depth-top of liquid to inlet invert: y" Depth of solids layer: /D" Depth of scum layer: "Orjc— Dimensions of cesspool: S/' p 1 gw � A 8'0e40 Materials of construction: 6oNc+2-e� Q16c-K Indication of groundwater inflow(yes or no): No Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 1. Page 10 of 11 OFFICIAL INSPECTION FORM=NOTFOR VOLUNTARY ASSESSMENTS SUBSURFACE`SEWAGE DISPOSAL"SYSTEM INSPECTION FORM PART C `SYSTEM'INFORMATION(continued) Property Address:./7/ �O N e./� DrtI'VC Owner: T64*%jLS tZ;441c6.,n 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._.-,__ ._ TT Acl e� S K.e-(c. , ti ; i 10 i Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) j Property Address: /7/ Df}►2naSTo+bde..- �H oz..630 Owner: 7c.r s 2: aaJ_5 Date of Inspection:__L2t_L/#/oZ .SITE EXAM. Slope 3Yo cyru-"OQe-- Surface water Iv oN C.-- Check cellar Shallow wells. Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: . f checked Obtained from system design plans on record-I date of design Plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked4ith local excavators,installers-(attach documentation) Accessed USGS database-explain: V S 6-S wed 1 Tom. �-�Y�f� �✓ 1 2_/LooZ ou must describe ow you established he high ground water elevation: GI�e.e_v< VSGS 2e.aan k fi pe-A NovjL4419=014TJ�4_ GV246-1- I1 �4 1� ,r E 1 Xt . . . . . . .. . . . . . wl -T f=_ x'T'309 B o oc) ., � r I� COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTALAAFFAIRS a DEPARTMENT OF"ENVIRONMENTA.L�PROTE_C_TI_ RE.DEIVED r• 9 .L ... 0EC. 8 2002 TOWN OF+BAPNSTARLE TITLE 5 ._ -8ALTN,DEPT. OFFICIAL INSPECTION FORM—. NOT FOR.VOLUNTARY"ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART-A CERTIFICATION Property Address: 17 1 /V i cN:: . P Co o e3ag MAP Owner's Name: ARCEL I Owner's Address: /7/ LOT . .__. �............. .. .. �AWSTAkJt MA Date of Inspection: Name of Inspector: (please print) ACTS. ["a Company Name• - - a� 6-t Ey� - Mailing Address: S3-.LtJk, eG'BoQ_wf l IhA1 ;H mA �z.6yq Telephone Number: $a4• y72_ 'Y72 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time'of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title (310 CMR 15.000).``The system: Passes Conditionally Passes . Needs Further Evaluation by the Local Approving Authority Fails Ins ector's Si ature: Y Date: P r� The system inspector shall submit a copy of this inspection report to the`Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the�system 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 3 of l 1 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAIU SYSTElVI INSPECTION FORM PART A CERTIFICATION`(eontinued)114 Property Address: L ctiry�- 8 MA Owner: J z M -5 YLI c,h cvc-cl� Date of Inspection: 02 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 y g p public health,safety and environment: system is functioning in a manner that protects the 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 ppm,provided that no other failure'criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 5 of 11 _OFFICIALTNSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B '= CHECKLIST Property Address: ✓7/ Td tv t c .,e. VSw,f S'T44Ae, MP o2 .......... Owner: T".►-e.5 Date of Inspection: l2 hak Z Check if the followinghave been done.You must indicate` s"or"no"as to each of the following: Yes No +-� Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection Were as built plans of the system obtained and examined?(If they were not available note as N/A) v Was the facility or dwelling inspected for signs of sewage back up Was the site inspected for signs of breakout? 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 no _ Existing information.For example,a plan at the Board of Health. Z— 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 7 of 11 OFFICIAL INSPECTION FORM-,NOT-FOR VOLUNTARY-ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART,C SYSTEM INFORMATION(continued) _ Property Address: / 7/ T®w"c, LL�,j-c rwbLc. /hA o�.630 Owner: � r.e:5 i2iC.lna�la� Date of Inspection: /o/X2 BUILDING SEWER(locate on site plan) Depth below grade: I, Materials of x construction: cast iron 40.PVC (explain): , Distance from private water supply well or suction line: ine: /V//4 Comments(on condition of joints;venting,evidence of leakage,"etc.): Goo Co"Doti.TvorJ.. . SEPTIC TANK:_(locate on site plan) Depth below grade: Material of construction: >C concrete metal—fiberglass_polyethylene If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) D _ 10 00 Dimensions: 0 Sludge depth: 6 Distance from top of sludge to bottom of outlet tee or baffle F : Scum thickness:. C 1. 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: ..U/L�J6;V/ t Comments(on-pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): w`•-. jponpe�A- dt�Nqk ;A..)S, torJ• . . GREASE TRAP:—(locate on site plan) Depth below grade 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: 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 9 of 11 OFFICIAL-'INSPECTION.FORM-rNOT:FOR VOLUNTARY ASSESSMENTS SUBSURFACE_SEWAGE�DISPOSAL SYSTEM_INSPECTION FORM PART C SYSTEM,INFORMATION(continued) . i Property Address: /7/ -ro jei ri,. "-e._ RgrL,ucT�,(y� rn�} 02630 ' Owner: ;TA W,0-5 a"C,4,.a.19-S _ Date of Inspection: I-Z -0- o- -- SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located ex lain.wh : , Type / ✓leaching pits,number: leaching chambers,number: Teaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding, damp soil,condition of vegetation, etc.): CT®� CpyJGQ.i?iOy-� NO p E!!21 . dtAAe>.,r✓ ,3,s e T Yid 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: 10" Depth of scum layer: Nonjc-�- Dimensions of cesspool: y' Q a�+• -es. A T�0e-#v Materials of construction: LoNc.+2c-to Q�a�-�'C Indication of groundwater inflow(yes or.no): N0 Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): -gip PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Dr`1t2nJSTo.bde-- /�sR oZ63D Owner: 7 s tZ ara,,L5 Date of Inspection:a/o/o-z— SITE EXAM Slope ,3% Chu`o _ Surface water ti ot•✓-_'_ Check cellar DAY 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) Accessed USGS database-explain: V S(r S w e.►a s i T-,C, You must describe how you established the high ground water elevation: �K.,p_C_V< VSG 'T;w i 11 f i i J �--°- E . 'T e o o� { No...... ..... ` ..... Ficis ................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........... ............OF..OMN..5V` k-E------------------------------------------- Appliratinn for Dispilsal Works Tonitrnrtion ramit Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal System at: ................T.Q.UQ12...ad..%...T.3rla t.a b1 Q........---•--••-•••-- ••-•••----...------•--••••--•-------•-----••-•--------•-•--•--••-••........---•-._.._......_--•••- Location-Address or Lot No. ..............+ .x . ..ca.WU-_--------•-----____--------------------•-----____-_-- .................... 0.uli naa Luidl.4..: ......... Owner Address W Cash' s Rtrudk11h% off Union StAddrd sarmouth, Ma Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms._3_......_................................Expansion Attic ( ) Garbage Grinder ( ) `L Other—Type T e of Building No. of ersons____________________________ Showers f� YP g -•------•------•--•--------• P ( ) — Cafeteria ( ) f4 Other fixtures -------------------------................ w Design. Flow____________________________________________gallons per person per day. Total-daily flow............................................gallons. WSeptic Tank—Liquid capacityl_Vp...gallons Length................ Width................ Diameter________________ Depth................ x Disposal Trench—No............c.._.___. 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---------------------------- erformed by--------------------------- -----•----•------------------•---------------- Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ( Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.............._......... -------------•----------------------------------------------•--....--------•---••-•-----•---•-------..................................... 0 Description of Soil--tb/•-v?•---&no—Vs.'.......................................................................................................... x w UNature of Repairs or Alterations—Answer when applicable.._I,-Q-cm;'._Llt"-I.___._ _ca-s :'�.r_e`._pi � y/�ats__.._.___. �rvc`,s�'! rw.�}„► ................................................. ................................................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITI..E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee ssued by the b rd o iealth a` Signed.- - �f ---------------------- ............Da--.............. Date Application Approved By.......... ...... --------------•-- ��=`I— , Date Application Disapproved for the following reasons:............................................................_................................................... ---------•-----------••----------------•-------------•----•------------••••----•-------.......----•---•...--------------------------•-•----•••---•••------•------•-•--••-----•-'- --•-----...-•- Date Permit No........ t ................... Issued_....... `............... Date -- -------- -- --- -- ------ ------------ -- W_.------- -- -------- No..--,....... Flss.1.5.................. 11 1 t THE COMMONWEALTH OF MASSACHUSETTS .. BOARD OF HEALTH ..........................................OF_....................................................................................... Applirtt#ion for Disposal Works Toustrttr,,tinn amit Application is h&eby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .................... ......................:.............. ....... - Location-Address or Lot No. Owner Address W ...-• .... ....................... Installer a Address Type of Building Size Lot............................Sq. feet 1•-1 Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No, of persons...... ..................... Showers a YP g --•-------•----------------• PF - ( ) — Cafeteria ( ) 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........s.......... Total leaching area..................sq. ft. Z Other Distribution box ( ) . Dosing tank ( ) Percolation1 suits Performed Test Pit No. nutes p r nch Depth of Test Pit.................... Depth to ground water........................ rZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -------------------------------------------------•-----•---•--....-•-----•-•------•---...._.._-•-•-•......................................................... 0 Description of Soil................:......................•........------------..............-•------...---------•-------------...----................................................... U -•••---•-----••-•-••-••••-•••-•--•-•--•----•••••••-------------------------•-••-••••....-----••••--•-•---•••--•-•••---•---•----.....---•-•-••--....--................................................. W --•------------------------------------------------------------------------------ -------------------------------------------------------------------------------------------------••••-----•-•--...... U Nature of Repairs or Alterations—Answer when applicable................................................................................................ -------------------•--•----------------•-------•----------•----------------........----...---------••----------------------------------------•------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T I T 114 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed...................................................................................... .........................._.... � r Date Application Approved BY = ''` ? -== .±............... •. =B 4 Date Application Disapproved for the following reasons:................. -- f ----------..................................... ...........•-•••••••-•-•••....................••••-••-•-.._...•--••••••••-••--••-•----........•-•---••-•---•--•••------••-•-•-------------------•-•••-••-•--------•------•••••••----••••••••---••------- Date Permit No.........R4 -_l111e.. •--- -------•-•----._...... Issued..... ..'...35...4:........... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH rr* .._OF..................................................................................... . C�rr�i�irtt�e of f�uttt�li�nr�e � THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by , --------- ----------------------------------------------------- ------------------- -' - ----••---•---Installer -' at.............................. �,`-.e...-.-... cr �M',itlr the rovis>ons of TI. 5 of The State Sanitary Code as described in the has been installed in a o� 'a � '" :- r ^ application for Disposal Works Construction Permit No........... �_____Ojr.'.�lj'_ __ dated--------- ._��jIIAT �-•---. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARA TEE T THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........ .. .0...-... ',rj....................................... Inspector........ ------- �ellot4vi... ...&AOL.,....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No................ �f ...........................................OF....... tiry...••... ... •---•---•-•-•----.....................---....... FEE...........1 ...... % ° = Disposal 10ork.5 Tvnolr tUatt Vrrufit Permissionis hereby granted................... I. ..............................................--=-----........---.........I.......----- to Construct ( ) or Repair. ( ) a Individual S mVa"gAe Disposal System atNo................................. `� .!......-.. •• ----.-••------- �= ............................. --••••••• ............... as shown on the application for Disposal Works Construction Permit Dated..... _g 4....... ....................... �� — --- ---------------------- —. 'Board of Health ' `•,k�`.�.�„k DATE...................../Z...........�.l.,•gt� -•-------•---------- ' i' FORM 1255 A. M. SULKIN, INC.. 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Leaching Pl s . WATER TABLE : FINAL INSPECTION BY: ` DRZA14ING OF INSTALLATION ON REVERSE SIDE: i J; ,;;�,... �l,hG�'�`�� � �. 1� ,..; �, ,� i -° f� �;: JJ v L O CAT ION SEWAGE PE RFAIT NO. VILLAGE INSTALLER'S NAME i ADDRESS 6 U I L D E R OR OWNER DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED - � RS