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HomeMy WebLinkAbout0015 CLIPPER LANE - Health 15 Clipper Lane Centerville P A = 189 009 I UPC 12534 No.2�OR `bsr.co ' HASTINGS, MN i i . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 15 Clipper Lane Property Address Pierre Turillon Owner Owner's Name information required for every lmstons-Mitts (fri rV i I I ti MA 02648 09/2.1/11 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not.be altered in any way.Please see completeness.checklist at the end of the form. Important:When A. General Information filling out forms rr the computer, use I b(o use only the tab 1. Inspector: key to move your cursor do not Michael Kellett use the return Name of Inspector key. Aardvark Environmental Inspections �y Company Name P.O.SOX 896 Company Address East Dennis MA 02641 Cityfrown State Zip Code 508-385-7608 St 3742 Telephone Number License Number B. Certification . _ I certify£ttiat I have personally inspected the sewage disposal system at this address and that the a , - information reported below is true,accurate and complete as of the time of the inspection.The inspection ca was peifoRned 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 a c ' Title 6(310 CMR 15A00).The system: ¢— cJ ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 09f2, Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use.. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Se a Disposal System•Page 1 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form "s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 Clipper Lane Property Address Pierre Turillon Owner Owner's Name information is Marstons Mills MA 02648 09/21/11 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) 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: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired'.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Check the box for"yes","no"or"not determined"(Y,N,ND)for the following statements.if"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts NEW Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments i�W�Y.- 15 Clipper Lane Property Address Pierre Turillon Owner Owner's Name information is required for every Marstons Mills MA 02648 09/2.1/11 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cunt.): ❑ 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 ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced' ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ 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 mannerwhich will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ® Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form Not for Voluntary Assessments 15 Clipper Lane Property Address Pierre Turillon Owner Owner's{dame information is required for every Marstons Mills MA 02648 0921/11 page. City/Town State Zip Code Date of Inspection B. Certification (coat.) 2. System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment:, ❑ The system has a septic tank and soil absorption.system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".. Method used to determine distance: *"This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the,analysis must be attached to this form. 3. Other: D) System Failure Criteria.Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® 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 ❑ 0 Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal.System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 Clipper Lane Property Address Pierre Tudllon Owner Owner's{dame information is required for every Marstons Mills MA 02648 090111 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No . ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ®' Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well'. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool.or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equa[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 2000gpd- 1'0,000gpd. ❑ ® 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 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. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 Clipper Lane Property Address Pierre Turillon Owner Owner's Name information is required for every Marstons Mills MA 02648 092111'1: page. Cityfrown State Zip Code Date of lnspedion C. Checklist Check if the following have been done.You must indicate"yes"or"no'as to each of the following: Yes No ® ❑ Pumping information was provided by the owner,occupant,or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week.period? ❑ ER Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as NIA) ® ❑ 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)P10 CMR 15.302(5)] D. System Information Residential Flow Conditions:. Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 t5lns-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments 15 Clipper Lane Property Address Pierre Turillon Owner Owner's Name information is required for every Marstons Mills MA 02648 09,2.1/11 page. Cityrrown state Zip Code Date of inspection D. System Information Description: Number of current residents: 0 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 ears usage 07111 g ( Y a9 (9pd'))- Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Dace Commercial/Industrial Flow Conditions: Type of Establishment:. Design flow(based on 310 CMR 15 203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings,if available: t5ris•1 VID 7We 5 Official..-specycn Fe.,,,:SubsL7ace Selvage Dspawl System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 15 Clipper Lane Property Address Pierre Turillon Owner Owner's Name information is required for every Marstons Mills MA 02648 09/21/11 page. City/Town State Zip Code Date of inspection D. System Information (coot.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 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/Altemative 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 VA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval.. ❑ Other(describe): t5ins-11110 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System.Form-Not for Voluntary Assessments 15 Clipper Lane Property Address Pierre Turillon Owner Owner's Name information is required for every Marstons Mills MA 02648 09/21/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components,date installed {if known)and source of information: 30 years Were sewage odors detected when arriving atthe site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: 1.6 feet Material of construction: ® cast iron Q 40 PVC ❑ other(explain): 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) If tank is metal,list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate). Q Yes ❑ No Dimensions: Sludge depth: t5;rs•'1110 Tits 5Ofr W inspettm Fern:Subsustace sav ags Dispawa� Page 9 of 17 Commonweafth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 15 Clipper Lane Property Address Pierre Turillon Owner Owner's Name information is required for every Marstons Mills MA 02648 0912111.1 page. City/Town state Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or battle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete El metal. E fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 Clipper Lane Property Address Pierre Turillon Owner Owner's Name information is required for every Marstons Mills MA 02648 0921/11 page. CityfTown 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.): 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 per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and,float switches,etc.) "Attach copy of current pumping contract(required).is copy attached? ElYes ElNo t5ins-11110 Title 5Ofi cial Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 15 Clipper Lane Property Address Pierre Turillon Owner 0omer's{dame information is required for every Marstons Mills MA 02648 09/21/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 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 Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Soil Absorption System(SAS)(locate on site plan,excavation not required): If SAS not located,explain why: t5ins•11110 Me 5 Official Inspection Form:Subsurface Sewage Disposal.System•Page 12 of 17 Commonwealth of Massachusetts a Title 5 official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 Clipper Lane Property Address Pierre Turillon Owner Owner's Name information is required for every Marstons Mills MA 02648 0921/11 page. Cityrrown state Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length:. ❑ leaching fields number,dimensions:: ® overflow cesspool number: 1 ❑ innovative/altemative system: Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): This system has a 6'z5'drywell block overflow pit which dry with:light staining 3"up from the bottom. Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration 2 inline Depth—top of liquid to inlet invert 58° 1 Depth of solids layer Depth of scum layer V. Dimensions of cesspool' Materials of construction Drywell Block Indication of groundwater inflow ❑ Yes ® No t5ins-11/10 Title 5 Official Mspecton Form:Subsurface Sewage Disposal,System-Page 13 of V r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 15 Clipper Lane Property Address Pierre Turillon Owner Owner's Name information is Marstons Mills MA 02648 0921111 required for every page City/Town state Zip Code Date of Inspection D. System Information (cunt.) Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): This is a drywell block pit which was in good condition with liquid 12"below the outlet invert and staining at the invert. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic failure,leveb of ponding,condition of vegetation, etc.): t5ins-11/10 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 r Cormnonwea6th of massachusetts Title 5 Official Inspection For Subsufface Sewage Disposal System Form-Not for Voluntary Assessments 15 Clipper Lane Property Address Pierre Turillon Owner Owner's Name information is Marstons Milts MA 02648 0921/11 regWred for every page. Citylrown Stabs Zip Code Date of tnspecuon D. System information (cont) Sketch Of Sewage Disposal System:Provide a view of the sewage disposal system,including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 31 a� t5hs•1 U10 Tdle 5 Officiai mspecuon Form:Subsurtace Sewage Dbp-W SySem•rage 15 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 Clipper Lane Property Address Pierre Turillon Owner Owner's Name information is Marstons Mills MA 02648 0921/11 required for every page. CityFrown 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: 20.0 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 Hearth-explain: ❑ Checked with local excavators,installers (attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS maps show an elevation of over 20.0 feet. Before filing this Inspection Report,please see Report Completeness Checklist on next page, t5ins-11/10 We 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 Clipper Lane Property Address Pierre Turillon Owner Owner's Name information is Marstons Mills MA 02648 0921111 required for every page. Cityrrawn State Zip Code Date of tnspection E. Report Completeness Checklist ® Inspection Summary:A, B, C,D,or E.checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 ' TOWN OF BARNSTABLE LOCAT10N SEWAGE # Qk VILLAGE C.e,K We- ASSESSOR'S MAP & LOT 0 "Ot7 INSTALLER'S NAME&PHONE NO. C CA AC Co oO Qwt LEACHING FACILITY: (type) D QCL, (size) 6 NO. OF BEDROOMS BUILDER OR OWNER I Ur i C�,O Vt- PERMITDATE: DATE: L2 Separation Distance Between the: Maximum Adjusted Groundwater Table to the 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 3t . �t M COMMONWEALTH OF . LAC RUS3ETTS EXE{,'UTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT.OF ENVIRONMENTAL PROTECTION s• MAP PARCEL LOT _ 5 - TITLE 5 OFFICIAL INSPECTION FORM[-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A / CERTIFICATION Property Address: /S� ; �- L..gn-.Q AfA 4C Owner's Name: rr n RECEIVED Owner's Address: Cl- i rTiy-. AIT D 7 _a718 Date of Inspection: // JUN 2 12004 Name of Inspector: (pl print) G l e& T TOWN OF BARNSTABLE Company Name: f j HEALTH DEPT. Mailing Address: Q o, Telephone Number: p 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.ofon,site.sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15340 of Title 5(310 CM 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails y Inspector's Signature: W.J Date: —-//8/0y 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 6/152000 p page I Page 2 of 1 1 OFFICIAL INSPECTION FORD—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address Owner r! o Date of Inspection: li Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: i� I have mot found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to replaced or repaired.The system,upon completion of the replacement or repair,as approved by the B of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following scat ents.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic (whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank i e is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as— ed by the Board of Health. *A metal septic tank will pass inspection if it is stru sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is av i le. ND explain: Observation of sewage backup or out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,se ed or uneven distribution box.System will pass inspection if(with approval of Board of Health): broken pipe(s)an iplacced obstruction is removed distribution box is leveled or replaced ND explain: The syste required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspectio if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of I I OFFICIAL. INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMEN17S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: /j L 1 e4 Owner: Date of Inspection: 1E3 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 sv m is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.3 1)(b)that the system is not functioning in a manner which will protect public health,safety and t 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 It marsh Z. System will fail unless the Board of Health(and Public ter Supplier,if any)determines that the system is functioning in a manner that protects the public ealth,safety and environment: _ The system has a septic tank and soil absorptio system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface wat supply. _ The system has a septic tank and SAS the SAS is within a Zone 1 of a public water supply. — The system has a septic tank and S S and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank d SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply welt".M od used to determine distance "This system passes if th ell water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile or is compounds indicates that the well is free from poIIution from that facility and the presence of amm a nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are bgered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of l l OFFICIAL INSPECTION FORD;—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE D OSAL SYSTEM INSPECTION FORM PART.A. CERTIFICATION(continued) Property Address• Owner: Date of Inspection: 6 //LgLo 51_ D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for ail 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 Jam' Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow Required pumping mote 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. o—� Any portion of cesspool or privy is within I QO feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. —� Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis..(This system passes if the well water..analysis, performed at a DEP certified laboratory,for coWorm bacteria and volatile organic.compowids indicates that the well is free from-pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is.equal to:or less than a 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 CUR 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 facility a design flow of 10,000 gpd to 15,000 1Td- You must indicate either"yes"or"no"to each of the folio ' (The following criteria apply to large systems in additi o the criteria above) yes no _ the system is within 400 feet of ce drinking water supply _ the system is within 200 f of a tributary to a surface drinking water supply _ the system is loc a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a pub' water supply well I If you have answere 'yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section above the large system has failed.The owner or operator of any large system considered a significant t under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. system owner should contact the appropriate regional office of the Department. 4 Page 5 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAI. SYSTEM INSPECTION FORM PART R CHECKLIST Property Address: / � k Owner: 70_0-X0 on Date of inspection: Check if the following have been done You must indicate"yes'or"no"as to each of the following: Yes No je, _ Pumping information was provided by the owner,occupant,or Board of Health .1' Were any of the system components pumped out in the previous two weeks ? Has the system received normal flows in the previous two week period — Have large volumes of water been introduced to the system recently or as part of this inspection? AIA 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 in enance 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)] I 5 Pate 6.of I 1 OFFICIAL. INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION , Property Address: zaef e { Owner: '� t Date of Inspection: ido= FLOW CONDITIONS RESIDENTIAL u Number of bedrooms(design):__�/ Number of bedrooms(actuaI). 7 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x##of bedrooms): WO Number of current residents: 0, Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): AoV f if yes separate inspection required] Laundry system inspected(yes or no):V Seasonal use:(yes or no):_1�145 Water meter readings,if available(last 2 years usage(gpd)) Q3 Sump pump(yes or no):-00��f={ Last date of occupancy: COMMERCIAL/LNDUSTRIAL, Type of establishment: Design flow(based on 310 CMR 15. gpd Basis of design flow(seats/perso sgft,etc.): Grease trap present(yes or n ._ Industrial waste holding present(yes or no):— Non-sanitary waste di arged to the Title 5 system(yes or no): Water meter read' ,if available: Last date of occ ancy/use: OTHER(d cr'be): GENERAL INFORMATION Pumping Records ^' Source of information: IUtz Reco d A {p tp'ur Was system pumped as pan of the inspection(yes or no): If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _Septic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all component,date installed(if known)and source of information: D. Were sewage odors detected when arriving at the site(yes or no):IlJO 6 Page 7 of 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE-SEW-AGE DISPOSAL. SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: c ftv - Owner: T Date of Inspection: BUILDING SEWER(locate on site plan) . Depth below grade: p?0 Materials of construction: cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc_): SEPTIC TANK:_(locate on site plan) Depth below grade: Material of construction:_concrete_metal____fibe alas _polyethylene _other(expiain) If tank is metal list age:_ Is age confirmed by a ificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: Distance from top of sludge to bottom outlet tee or baffle: Scum thickness: Distance from top of scum to to f outlet tee or baffle: Distance from bottom of sc o bottom of outlet tee or baffle: How were dimensions de fined: Comments(on pump' recomment ons,in and out tee or baffle condition,structural integrity,liquid levels as related to outlet ert,evidence eakage,etc.): GREASE TRAP:_(locate on site plan) Depth below grade: Material of construction: concrete _fiberglass_polyethylene—other (explain): Dimensions: Scum thickness: Distance from top of scum to p of outlet tee or baffle: Distance from bottom of s m to bottom of outlet tee or baffle: Date of last pumping: Comments(on pump' g recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet' vert,evidence of leakage,etc.): 7 I Page 8 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C = SYSTEM INFORMATION(continued) Property.A-dv'6064— ddress: /s i Owner: / u ' j 2; Date of Inspection: (,/(6 OT y TIGHT or HOLDING TANK: (tank must be pum at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete me fiberglass`polyethylene other(explain): Dimensions: Capacity: /mworking Design Flow: y Alarm present(yes or Alarm level: der(yes or no): Date of last pumping:Comments(conditiotches,etc.): (DISTRIBUTION BOX: (if present t be opened)(locate on site plan) Depth of liquid level above outlet ert: Comments(note if box is leve d distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box, c.): PUMP CHAMBER: (Iocate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pum amber,condition of pumps and appurtenances,etc.): Page 9 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ��i �-.4 Owner: i a-1 Lbow Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number._ leaching chambers,number. leaching galleries,number. leaching trenches,number,length: leaching fields,number,dimensions: 0 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 veeetation, etc.): CESSPOOLS: k (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: OZ ( Iti tk-4 Depth-top of liquid to inlet invert: Depth of solids laver: s-a — Depth of scum layer: dam' Dimensions of cesspool: X.YS' Materials of construction: f aj tu_b lac-fe Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hy draulic fail e, level of ponding,condition of vegetatio ,etc.): I it ms y c 'I Woe _�//�� Q k PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note co ition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address- / � (t ,f ✓c fit* Owner. I J r% 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. t� � t 31 in Page I I of 11 OFFICIAL INSPECTION FORM—NOT FOR VOI.,IJTNTAR L ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFOR1VIATION(continued) Property Address: Owner: /` Date of Inspection: SITE Etyit Slope Surface water 117 Check cellar &S Shallow wells . Estimated depth to ground water�t 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 desip plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: a O aQ , ii TOWN OF BARNSTABLE LOCATION SEWAGE # ASSESSOR'S MAP & LOT/0_ oa9 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITYC - XIo y- 6es5�. LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the 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 eeOW r 53., a0 s plc Pilos