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HomeMy WebLinkAbout0085 VANDUZER ROAD - Health i 85 VAN DUZER ROAD, BARNSTABLE A=352-033 p wL 7-- TOWN OF BARNSTABLE LOCATION <-S- IZA A) p U 7.-2(Z. fzrj SEWAGE # VI's LAG1i`�1Q 1N C��b h k ASSESSOR'S MAP&LOT A 1 INSTALLER'S NAME&PHONE NO.12 Cx/fZ C-SSn6 V 3 a -G 530 SEPTIC TANK CAPACITY l LEACHING FACILrrY: (type) (size)„ . NO.OF BEDROOMS BUILDER OR OWNER Q-�--ri 2 PERMITDATE:3' 1 ` �/ � 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�le chin facili Feet Furnished by !L i 4 V r M S C ro J M LOCATION SEWAGE PERMIT NO. tVI,LLAGE a _ r I N S T A LLER'S NAME D ADDRESS 0 U I L D E R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED a z } 60 0�0 �� d 21 Fss...... .._............... THE COMMONWEALTH OF MASSACHUSETTS f BOAR® OF HEALTH R ...................... ............. ....OF.................,...-.................. ��aJZ Appfiration for Dig ati al Work,6 Tontitrurtiun ramit .I Application is hereby made for Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal System at: vN S ` Location-Address V or Lot No. . Y?r/ -------------------------------- ------------- ------............-•---•--................--•------- Owner / Address ..... '`�r",�t a try/1 ...--- ........................................... Installer Address dType of Building Size Lot............................Sq. feet V Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) '4 Other-7-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 ( ) '-� Percolation Test Results Performed by.......................................................................... Date........................................` aTest Pit. No. I................minutes per inch Depth of Test Pit..........._:....... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.................... 0 Description of Soil......................................................................................................................................................................... x -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----- --•••- V Nature of Repairs or Alterations—Answer when applicable._...._ /1 ?.'1V/---..._._J�r�__._------ �?/��i?...�PZ.�.� ZA Agreement: r The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance hayb-Rp issued by the oard of health. Signed - •-•-••- --...... J to Application Approved By.................. a :�; ---- - -------------------- ------- i�j��I..-------- Date Application Disapproved for the following reasons:.....-- ------------------------------.......................................................... -•-••-•-•---•--••........•-•-••----•-••••-•••••-••--••--•••--•--•-•-••••-••••--•-----------•-•-----•••----••-••-•----•-•-...... ---••--•••-•--•••-••-- Date PermitNo........................... -----_----------------------- Issued_......................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...................... ....................OF..................................... Appliratinn -fur Disposal Works Tonstrurtinn Frrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .. [.Y�.t✓_> .tV.1s>, #!..... __..... G.v��1.at/Sj�!l ----••------•---------------------•--------- ---- ---•---••-----..............-•-------......--- - ,1 L Location-Address or Lot No. j�.......... Chi' :21,C................................. .•---...............---------................-•----......................-•----................... Owner 1 Address ,Wa --•- .1,4422n.5........... /----. e!✓............. ......................... Installer Address UType of Building Size Lot...................:........Sq. feet ►.., Dwelling=No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building No. of persons ....................... Showers � YP g ---------------------------- P ( ) — Cafeteria ( ) dOther fixtures -----•-------------------------•----------------•-•----••--•---•-•---•----••--•----•... - W Design Flow............................................gallons per person per day. Total daily flow......................:.....................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No................:.... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( )- Percolation Test Results Performed bY--------------------------•- : --..-•------------•-••-•--------•----•-•-••-- Date........................................ a Test Pit No. 1................minutes per inch Depth of Test Pit._______........._.• Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 ------------------------------- .--•-------- ----------------------- -........... •........ -----•-------------- ------------------------- •------------------------ 0 Description of Soil........................................................................................................................................................................ x V .......•••-•-•---•--•-----•-••--•-•---•-•-------------------••---------------......•---------•--•••-------•-•--•••---------•••----•••••--••--•-•----•••••••-----•-----•------.......---••---••••--•-•--- W U Nature of Repairs or Alterations—Answer when applicable--------/ .—V!2411-___-___lj✓�. .C. ............ ---------- ---•--•....------.. ... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITI2 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance ha been issued by the and of health. Signed..... ,il_- ,Date Application Approved BY -----•••...._._ .......�.a. _� ` _.. ................ -----• ----Da L...------ te Application Disapproved for the following reasons______________________________________ -------------- ......•--....-- ..............•--------------.....•.......-------------------•---------------------------------------------••••-•••-•--••---•••---•-•--••----•-------------••••-•--•--•-•------••...•--•-------••------- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... C�rr#i�irtt#r of faum�rlt�anr� THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) bY------------------------ :--------........:----..---.........----•-......-------- ------------......-----...............-----........------------------------. �. - Installer at---------------"---`-`- '��.��--=---�=�-e?!''�' -------- " ------- -'-' =='"-'-'w`=.• 'G"".,`.,.,.1--------------------------------------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of TheState Sanitary Code as described in the application for Disposal Works Construction Permit No.___.�....."..._r dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.............................................?.P-S.19 !.......... Inspector---------......-------- > .................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH O F.......................... - ...................... ........................................................... No.-- .... ..�' FEE.......s............ Disposal Works Tonotrndion rrmi# Permission is hereby granted.----- '7 .... �-11.='=''°ti`=-----------------------------------------------------------•-•-------.--.-...--•--........ to Construct orRepair ( .an Individual Sewage Disposal System at No. �s«......... ......... .....C_�"��'" r -------------- Street✓ as shown on the application for Disposal Works Construction Permit �/{No �o.. .....�......._�__. Dated...........................•.•........... lll , ard of Health DATE.................................. -3, -4...-•............... FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS • � vas= �� �J� xl0 C T ION 4 SEWAGE PERMIT NO. ,`�NILLACE I N S T A LLE0'S MANE A ADDRESS i U I l D E R OR OWN ER X DATE PERMIT tSSUEQ DA-T- E C_OMPLIAN.C_E ISSUED I� co/ rl `. PP •3 ASSESSORSMAPNp =F �1- ~ i - PARCEL NO: ._� _ No................. �' FRs... ....... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Apphration for Dhipwial Murk,6 Cnontitrurtiun Pumit Application is hereby made for a Permit to Construct ( ) or Repair (/an Individual Sewage Disposal System at: VAO L cation-Addrressss /� o f Lp t No. LJJ Owner Address a ..........1, ------ --�-r--- -------•----•--------------------------------- M,4-j t w.c y'� Installer Address PQ UType of Building Size Lot............................Sq. feet Dwelling— No. of Bedrooms-------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons------------_-------- -- Showers ( ) — Cafeteria ( ) Otherfixtures -------------------------!........................................................................................................................ W Design Flow-------------------_----...................g ons 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........................................ 1 Test Pit No. 1................minutes per inch Depth of Test Pit...--............... Depth to ground water..-.-------------------- µ, Test Pit No. 2................minutes per inch Depth of Test Pit..----------.------. Depth to ground water........................ 9 -------------------------------------------•----------------------------------------..........-------------•--•--••------•••••----••---•-----•-----------. ODescription of Soil-----------------------•-----------------------------------------------•----------------------------•----...--------•-------------------------------••••-•...........--- x x U Nature of Repairs or Alterations—Answer when applicable .,K.c_ ... -..K-�_'P-s ........................................ --------------------------�?- �` -- `''� :F "�.�"r' u..iT�J -- '` ' v=$ 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 been issued by the board of health. Signed ---- ------- "�- - ...... o .. . 7.: -- ' Dace Application Approved By - Lc %/Z ---- ------------------------------------------ Dace Application Disapproved for the following reafons: .......... ..........:............................. . ............. ........................ ------------------- ------------------------------------------------------------------------------ ----- --------------------------------- --- --- ------------------------- --------------- Permit No. ..`. . r....V... .........................._ Issued .... `�_ ,�..`: .................... Dare 1�7 4-4 No................-..... Fimic ....... .THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Dbjpuml Worlai Towitrnrttun Valuit Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal System at: �� I 'R S— V A O ID v'Z�e R I `�'I J . ........................•---•-------.........--------------•--•---------------------•------------- --------•---------------------------------------------............-----•------------...----------- L cation-Address or Lot No. Owner `Address / W Installer Address QType of Building Size Lot............................Sq. feet V Dwelling— No. of Bedrooms---------------------------------------_.--Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ------------------_------- No. of persons............................ Showers ( ) — Cafeteria ( ) 04 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 ( ) aPercolation Test Results Performed 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--_-.---.----_----_-_-_. a ---------------------------------•-----------------------•------------•-----•--•••--........--------........................................................ 0 Description of Soil........................................................................................................................................................................ x U ------------------------------------------••--------._...------------------•-----------------------------•-----------------------------------...-------------•----------.............------.._..-------- x ------------------------------------------------------------------------------------------------- -- - ---- -- ---------------------------------------------......... U Nature of Repairs or alterations—Answer when applicable.l. .'P. .� ..._-{___ ....................................... ........................................................ ......�-1}-'- 6-p...................................................... 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 been issued by the board of health. %. , a. -D,-3Signed ----..t ./........ .............. -------------------------------------- e Application,Approved By .' ............ '..... --- ------------------------------------------------ ---------------- . Dare Application Disapproved for the following reasons: ............................ -.............------------------------....--------------------------------------------------- ----------------------------------------------- ---- --------------------------------------- � Date a Permit No. .......... .......... �. ...................... Issued .... .. f' , Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE l.Ler#ifirate of C�nmplian e THIS IS TO;#RTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( / ) by .....................------------ ....-----.G..�. �-------------------------------------------- _..._.. ... Insndler L/ /J v Z (t n / -------- at .... ...S ...... .- --- ---- °�----------------------- ----`�....... .R..JJ.--S` ^X� ........- - - has been installed in accordance with the provisions of TITLE 5 of,TheState 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. L� L DATE..... �1�.`. . ..-..... --------- -------- ---------------------- Inspector ......................... --------------- ----_---- ---------------------.... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ,ems TOWN OF BARNSTABLE Now. FEE. � "� urkii ToMitrurtiun '"amit Permission is hereby granted------- �...--- -----.P-rl!---------------------------------------- ----------------- to Construct ( ) or Repair (Zf an Individ�jal ewage Disposal System at No..� ........ ' -�----D(�Z!f_.A ``rV.-----......117.A01-.3��0�I ................................ .................. Street as shown on the application for Disposal Works Construction Per it,1�1�"_ ��____ Dated�*'_......./........._�.... ..._.. ----�•:•--- �---'=-''='�,.r�.�.1-..�----_-f� - ..___��'-''f-fir-------------- .— ! ---------------- FORM Board of Health /' DATE...... ----------�--•%--- 36508 HOBBS&WARREN.INC.,PUBLISHERS v OWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE ", ASSESSOR'S MAP &LOT - INSTALLER'S NAME&PHONE NO. �3 SEPTIC TANK CAPACITY LEACHING FACILITY: (type)---- 4c>' (size) -�X NO.OF BEDROOMS BUILDER OR OWNER6'�� P � ��'��l `--/`�?; 9 e, 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 /LIl �� V Commonweafth of Massachusetts FEE Executive Office of Environmental Affairs W'` 1996 , _Department of � Environmental 'Protecfion pl. Ot� WUllam F.Weld teowmor T yv.[�► Div(d B.Struhs .;;Oonrnlpbner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 85 Van Duzer Lane Cummaquid Address of Owner: 10 Charolette Road Date of I nspedion: 1/18/9 6 (If different) Marblehead, MA Name of Inspector: Donald Klimm ` Company Name,Address and Telephone Number: Robert B. Our Co. , Inc 1-508-432-0530 CERTIFICATION STATEMENT 24 Great Western Road, Harwich, MA 62645 I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of 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: _ Passes Conditionally Passes Needs Further,Evaluation By Local_Approving Authority. x , Fails ' t Inspector's Signature: Date:' ,� g 1 C�d � The.Systmor shall submttfa copy of:this inspection report to the Approving Ateftonty,within thirty(30)days of completing this inspection afht3y�stem is a;hired system or has a.design flow of 1.0,000 gpd orreater,4tie inspector and the`system owner shall submit the report to -regionalToffice of the Department-of-Environmenta, -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. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, 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 exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8/15/95) 1 One Winter Street 9 Boston,Massachusetts 02108 0 FAX(617)556-1049 • Telephone(617)292-SSW r `�.. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) ` Property Address: 85 Vanduzer..Lane,: Cummaquid Owner: Dexter Koupman Date of Inspection: 1/18/9 6 B] SYSTEM CONDITIONALLY PASSES (continued) 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.re. placed . _ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: , 4' 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 BOARWOF HEALTH MD 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 SVcleM i,d�, a septic tank and soil absorption system and is wit i 100 fee,to a surface water supp!y cr 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 less than 5 ppm. D] SYSTEM FAILS: x 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. cesspool. x an overloaded or clogged Backup of sewage into facility or system component due to SAS or Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. (revised 8/15/95) 2 r - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 85 Vanduzer Road, Cummaquid . Owner: Dexter Koupman Date of Inspection:1/18/9 6 f D]SYSTEM FAILS(continued): y Static liquid level in the distribution box above outlet invert due to an overloaded or dogged SAS or cesspool. Y Liquid depth in'cesspool is less than 6"below invert or available volume is less than 112 day flow. n0 Required pumping more than 4 times in the last year NOT due to dogged or obstructed pipe(s). Number of times pumped n0 Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. n0 Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. n0 Any portion of a cesspool or privy is within a Zone 1 of a public well. ria Any portion of a cesspool or privy is within 50 feet of a private water supply well. n0 Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water wpply 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. w Y• i n .. .Y. -..tilt' _ .. ... s ' -..� E]LARGUSYSTEM.FAILS: The following criteria-apply:toiarge-systems in addition to the tnteria-above: The design flow of system is 10,000: g y gpd or greater (Large System)and the system is a significant threat to public heahh and safety and the environment because one or more of the following conditions exist _ the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area(IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. • 5 (revised 8/15/95) 3 e� • 4 SUBSURFACE SEWAGE DISPOSAU-SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 85 Vanduzer Lane Cummaqui.d Owner. Dexter Koupman Date of Inspection: 1/18/9 6 Check if the following have been done: _Pumping information was requested of the owner, occupant, and Board of Health.. Y None 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. T: Y As built plans have been obtained and examined. Note if they are not available with N/A. Y The facility or dwelling was inspected for signs of sewage back-up. Y The system does not receive non-sanitary or industrial waste flow Y The site was:inspected for signs-of breakout. Y All system:components, excluding the Soil Absorption System, have been located onthe site. Y The 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. `;. _ • - --- =. fir ;:._. . . -- --��:' ;�___�_ .: _ _. .. �_sw _...... _ . _._..._._ Y The size aid location of the Soil Abso ion System on the site has been determined based on existing information or apProxurraftdtb) won-intrusweneihods. Y The facilitj 6-%vner (and occupants, if differen( from.owner) were provided with information on the proper maintenance of Sub.. Surface Disposal System. (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Dexter Koupman Owner: 85 Vanduzer Road Cummaquid -Date of Inspection: 1/18/9 6 FLOW CONDITIONS RESIDENTIAL: Design flow: 3 2 0 gallons Number of bedrooms: 3 ' Number of current residents: 2 Garbage grinder(yes or no):no Laundry connected to system(yes or no): Y e s Seasonal use(yes or no):__ap Water meter readings, if available: 1 Last date of occupancy: now ,c ' COMMERCIAUI NDUSTRI AL• Type of establishment: Design flow::; Pilo'ns%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)_ t Water meter readmgs;.if.available: Last date of occupancy: OTHER: (Describe) Z. - ----. Last date of occupancy:____.,. GENERAL INFORMATION PUMPING RECORDS and source of information: Pumped in 1995 System pumped as part of inspection: (yes or no)_nD If yes, volume pumped. 1000 gallons Reason for pumping: TYPE OF SYSTEM x Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy flo_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: Installed in 1989 7 years Sewage odors detected when arriving at the site: (yes or no) no (revised 8/15/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 85 Vanduzer Road, Cummaquid Owner: Dexter Koupman Date of Inspection: 1/18/9 6 SEPTIC TANK: x (locate on site plan) Depth below grade: •6 ' Material of construction?{ concrete metal _FRP_other(explain) Dimensions: 8 ' 6" L x 4 ' 10"W x 5 ' 10" D ' Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: ". Scum thickness: none Distance from top of scum to top of outlet tee or baffle: 5" Distance from bottom of scum to bottom of outlet tee or baffle: 2 3" Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to,outlet invert, structural integrity, evidence of leakage, etc.) ;1. ' no leakaie - Tees in good thane no vegetati nn GREASE TRAP:— (locate on site plan) Depth below grade._ '— Material of construction: _concrete _metal _FRP other(explain) Dimensions: Scum thickness. Distance from top of scum to top of outlet tee or baffle: Distance from bottom of srum t- 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, etc.) (revised 8/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued)- Property Address: 85 Vanduzer Road Cummaquid Owner: Dexter Koupman Date of Inspection: 1/18/9 6 TIGHT OR HOLDING TANK:_ (locate on site plan) Depth below grade: Material of construction:_concrete=metal_FRP—other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet-tee, condition of alarm and float switches, etc.) _ Y A DISTRIBUTION BOXY (locate on.site.plan)_ -.... Depth of liquid level above outlet invert: ._,r. . Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)w- Tinknnwn is under shed PUMP CHAMBER:_ (locate on site"plan) Pumps in working order.(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 85 Vanduzer Road, Cummaquid Owner: Dexter Koupman Date of Inspection: 1/18/9 6 SOIL ABSORPTION SYSTEM (SAS): x (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: P Type. leaching pits, number:_ leaching chambers, number: 2 4 x 8 flow diffusors witYj 2 ' of stone 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 vegetation,etc.) Shows signs of hydraulic failure Found full on 1 17/96 L.i aht `veaetati on CESSPOOLS: _ (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(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 plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 8/15/95) 8 r � t. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) i Property Address: ---T- Owner: Date of Inspection: � � - E J' ,0 m SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent referer ces landmarks or benchmarks i locate all wells within 100' C '�✓` 3 �O G i i i %S h©ice (� 3 Shy m p.. C.-. ,t DEPTH TO GROUNDWATER- - Depth to groundwater: `� feet method of determination or approximation: C (revised 8/1S/95) 9 Ln �} h THE COMMONWEALTH OF 1VIASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION � BE ITI� NO THAT t, t a z r W77, D®nald� Kl_i ot, a W Has r sat sfiied- Oii Departments's,«qualificat`ions-- , q y as re tired'.and is hereby authorized.to use tier{title CERTIFIED TITLE. 5 :SYSTEM INSPECTOR as, provided. in 310 CMR 15 34.0 and Section fig13 of Chapter 2 1 A of the .r General Laws: Issued }by The� Dep;art�iienxQf%EnvironmentalProtection. F,;� r �•t March 16, 1995 } - Actin ;Director of the ion of Water Pollution Control