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HomeMy WebLinkAbout0873 CRAIGVILLE BEACH ROAD - Health 873 CRATGVII,LE BEACI-I RD., C'V A= 225 031 IN i I ij �nt�W� 2J� Co2m UPC 12543 Now HASTINGS,MN ,a°. a Town of Barnstable Barnstable Inspectional Services Department ;edc j x zvs�raeLEE 6 Public Health Division �? a6�9• �`b m Arf��ys 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas A.McKean,CHO FAX: 508-790-6304 CERTIFIED MAIL#7015 1730 0001 4988 2088 January 18, 2019 MISCHIK, KATHLEEN KING 6 PHEASANT RUN HINGHAM, MA 02043 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 873 Craigville Beach Road, Unit#3, Centerville, MA was -inspected on 01/10/2019 by Patrick T. Sullivan, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Conditionally Passes" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Lines from distribution box to leaching chambers are damaged causing back up into the distribution box and septic tank. You are ordered to repair or replace the septic system within two (2) years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE B ARD OF HEALTH a S., Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Conditionally Passes Letters\873 Craigville Beach Road Unit 3 Centerville.doc o�TME � ' Town of Barnstable i w � 1ARNSTABIF.. • 019. Regulatory Services Department Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 5/11/16 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An"x"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1) YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑ Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool 'Any "conditionally passed systems" (broken cover relocation of a pipe, relocation of a driveway due to H-10 components, etc) n Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER Repair deadline.. Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc as 6 031-00"' � Commonwealth of Massachusetts COP,� e �' r� Title 5 Official Inspection Form �a h Ih Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' 873_Craigville Beach Road u- _ _ Property Address F Kathleen Mischik (Unit 3) Y Owner Owner's Name — information is t required for every Centerville MA 02632 January 1`0, 2019 ry' page. City/Town — 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. Inspector Information filling out forms p on the computer, use only the tab Patrick T. Sullivan key to move your Name of Inspector cursor-do not Ready Rooter Excvatin use the return --_� key. Company Name PO Box 89 Co Company Address — '} Forestdale MA 02644 City/Town State Zip Code 508-509-0802 S112843 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ❑ Passes 2. ® Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails — January 16, 2018 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. 15insp.doc•rev.7/2612 01 6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 4 � Commonwealth of Massachusetts - - -, Title 5 Official Inspection Form — v Subsurface Sewage Disposal System Form - Not for VoluntaryAssessments 873 Craigville Beach Road Property Address Kathleen Misc_hik (Unit 3) Owner Owner's Name information is required for every Centerville MA 02632 January 10, 2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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.- 2) 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 i Commonwealth of Massachusetts MI Title 5 Official Inspection Form '7 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 873 Craigville Beach Road _ Property Address Kathleen Mischik Unit 3 Owner Owners Name — information is required for every Centerville MA 02632 January110, 20.19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ® 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): Lines from d-box to leach chambers are damaged causing back up into d-box and septic tank. ❑ 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): 3) 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. a. 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: f t5insp.doc•rev.7/26/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form — - Jl Subsurface Sewage Disposal System Form - Not for Voluntary ry Assessments c \aa 873 Crai ville Beach Road Property Address Kathleen Mischik (Unit 3) Owner Owner's Name information is required for every Centerville MA 02632 January 10, 2019 page. Cityffown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: 4) 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 t5insp.doc•rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts -;P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 873 Craigville Beach Road Property Address Kathleen Mischik (Unit 3) Owner Owner's Name information is required for every Centerville MA 02632 January 10, 2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 '/z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply 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 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system 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—IWNPA) or a mapped Zone II of a public water supply well t5insp.doc-rev.7/26/2018 I Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 f,: Commonwealth of Massachusetts i Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 873 Craiqville Beach Road PropertAd y dress _ - Kathleen Mischik Unit 3 Owner Owner's Name - information is required for every Centerville MA 02632 _ January1 0, 2019 _ page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes"or"no"for each of the following for all inspections: 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) ® ❑ 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)] I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 6 of 18 Commonwealth of Massachusetts -, Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form Not for Voluntary Assessments 873 Crai ville Beach Road Property Address Kathleen Mischik (Unit 3) Owner Owner's Name information is Centerville required for every _ MA 02632 January 10, 2019 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 8 Number of bedrooms (actual): 8 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 880 Description: 4 units with 2 bedrooms each. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ® Yes ❑ No Water meter readings, if available last 2 ears usage d 2017= 120 GPD g ( Y g (9P )) 2018= 98 GPD Detail -- Property used during summer months only Sump pump? ❑ Yes ® No Last date of occupancy: September 30th Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts -P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 873 Craigville Beach Road Property Address Kathleen Mischik (Unit 3) Owner Owners Name information is required for every Centerville MA 02632 January 10, 20_1_9_ page. City/Town _ State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: — — Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available.- Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Owners records: Pumped September 2018 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts __-_; Title 5 Official Inspection Form in b Susurface Sewage Disposal System Form P Y Not for Voluntary Assessments 873 Craigville Beach Road Property Address — — Kathleen Mischik Unit 3 Owner Owner's Name - - ) information is required for every Centerville MA 02632 January 10, 2019 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known) and source of information: System installed 08/15/1995. Certificate of Compliance on file at Health Dept. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 r Commonwealth of Massachusetts -19 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 873 Craigville Beach Road Property Address Kathleen Mischik (Unit 3) Owner information is Owner's Name required for every Centerville MA 02632 Janua 10, 2019 page. Citylfown �—_ion_ State Zip Code Date of Inspect D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass 9 ❑ polyethylene ❑ other(explain) If tank is metal, list age: _ years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 12.5' x 6.5' x 5' 2000 gallons Sludge depth: <1" Distance from top of sludge to bottom of outlet tee or baffle 37 Scum thickness <11, Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 16 How were dimensions determined? Dip tube and tape measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet tees in place. Liquid level at outlet invert. Risers bring inlet cover to grade with metal ring and cover, outet cover within 4" of grade. Tank shows signs of being overfull. Recommend maintenance pumping every tv„o years. t5insp.doc•rev.1126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts n= Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form - Not for Voluntary Assessments sue% 873 Craigville Beach Road Property Address Kathleen Mischik (Unit 3_ Owner Owner's Name information is required for every Centerville MA_ 02632 JanuaV 0, 2019 _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: -- i i Scum thickness / -- i Distance from top of scum to�top of outlet tee or baffle Distance from bottom of cum 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.): 8. Tight or Holding Tank (tank must bepumped at time of inspection) (locate on site plan): i Depth below grade.- Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions.- Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title.5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 L Commonwealth of Massachusetts WI Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 873 Craigville Beach_Road Property Address Kathleen Misc_hik Unit 3) Owner Owner's Name information is Centerville MA 02632 -Janua 10, 2019 required for every -January page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: / ❑ Yes ❑ No Alarm level: - Alarm in working order: ❑ Yes ❑ No Date of last pumping: i`, Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert .5 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.): One inlet, two outlets. Liquid level slightly above outlet inverts due to back pitch in first 2' of lines. Camera used to inspect lines and locate SAS. Lines are separated and need to be replaced. High staining over outlet inverts due to damaged lines. t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form t I, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 873 Craigville Beach Road Property Address Kathleen Mischik (Unit 3) Owner Owner's Name -- information is required for every Centerville MA 02632 January 10, 2019 _ page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: �^ ❑ Yes ❑ No` Alarms in working order: j' ❑ Yes ❑ No' Comments (note condition of Rti/mp chamber, condition of pumps and appurtenances, etc.): I If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required).- If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 8- Flow difusorsw/3' stone ❑ leaching galleries number: --- ❑ leaching trenches number, length: -- ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: - t5insp.doc•rev.7/26/2018 Title 5 Of dal Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 11 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 873 Craigville Beach Road Property Address Kathleen Mischik (Unit 3) Owner Owner's Name information is Janu Centerville MA 02632 a 10, 2019 required for every _ _ _ __ ry page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SAS located and inspected with camera. 3.5' below grade. Units dry at time of inspection. No sign of high water staining of past hydraulic failure. Once lines are repaired system will "Pass" inspection. 12. 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 — 1 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.) i t5insp.doc•rev.7/2.6/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 �; Commonwealth of Massachusetts Title 5 Official Inspection Form - Il Subsurface Sewage Disposal System Form -Not for Voluntary Assessments < � 873 Craigville Beach Road Property Address Kathleen Mischik Unit 3) Owner Owner's Name information is required for every Centerville MA 02632 January 10, 2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): j Materials of construction: i i� Dimensions Depth of solids Comments (note condition of soil, signs,of hydraulic failure, level of ponding, condition of vegetation, etc.): / t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form — Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y� •(r 873 Crai ville Beach Road t-r g -- Property Address Kathleen Mischik(Unit 3) Owner Owner's Name information is Centerville MA 02632 January 10, 2019 required for every _ ►� page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. 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 i i I i I I I I � i I • I iI � L I �1—I__- 1---- -`— — —'I--`-----'--1`---'—I---� _�----� i W 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 873 Craigville Beach Road Property Address Kathleen Mischik (Unit 3) Owner Owners Name information is Centerville MA 02632 January 10, 2019 required for every _ ry page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 4 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: 1995 -- 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: maps.massgis.state.ma.us/oliver.php You must describe how you established the high ground water elevation: Test hole in 1995 found adjusted ground water 8' below grade. Base of units are 4' below grade. Accessed local ground water contours and topo mappin_q. _ Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 873 Craigville Beach Road Property Address _Kathleen Mischik (Unit 3) Owner Owner's Name information is a Centerville MA 02632 January 10, 2019 required for every _ � _ page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 18 of 18 3y3 No, Fee w THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes—�� PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS applitation for Disposal *pstrm Construction Permit Application for a Permit to Construct( ) Repair(Xupgrade( ) Abandon( ) ❑Complete System �ividual Components Location Address or Lot No. ?72 T,A'---7 cap��l°! wner's Name,Address,and Tel.No 7�4J'a �3 Assessor's Map/Parcel v, Installer's Namt Address,and Te.No. Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) �; , t� `� L�..dfa�ti—�.�M-o w& Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. geed Date Application Approved by ' Date s Application Disapproved by Date for the following reasons Permit No. © ` — Date Issued 3y3 No. } Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yew/ !1. PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2[pplication for Mieppsal 6pstem Construction permit Application for a Permit to Construct( ) Repair(grade( ) Abandon( ) ❑Complete System Zridividual Components Location Address or Lot No. ?7 3 L s ;�cam,\��c e C Owner's Name,Address,and Tel.No.7?-(_�j O-Y34�_ Gera-v. Assessor's Map/Parcel O �CL Installer's Name,Address,and Tel.No. S®�?77— Designer's Name,Address,and Tel.No. `Q cQ_ Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) a Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil ' Nature of Repairs or Alterations(Answer when applicable) .-e - _r. f tpc, (� JI, 'V ELT v Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. , ed Date Application Approved by Date r Application Disapproved by Date for the following reasons Permit No. " t✓` Date Issued -------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS fop Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( ) a� Abandoned( )by at '�-Z �',., lK( 1-4- G�'�_c C has b-ReWTAstructed in accordance 4 G '-�! dated 5 with the provisions of Title 5 and the for Disposal System Construction Permit N Installer Designer #bedrooms Approved design flow and The issuance of this p it shall not be construed as a guarantee that the system will`n rasdesigned. Date 6 I �1 Inspector {, l � t ------------------------- -- ----------------- ---- -- r , . No.Q 1� / Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS �iStlDBal �pitem Construction permit \� Permission is hereby granted to Construct( ) Repair� Upgrade( ) Abandon( ) System located at `� the A 42 , ,' ,Q -'R a. 1 and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction mVe com-l]et within three years of the date of this pe Date / Approved by CRAIGVILLE REALTY CO P.O.BOX 216 648 CRAIGVILLE BEACH ROAD WEST HYANNISPORT,MA 02672 TEL: (508)775 3174 FAX: (508)7715336 E-MAIL: martinclay@comcast.net www.craigvillebeach.com July 23, 2007 Town of Barnstable Main Street Hyminis,MA 02601 ATTN: Tom McKean RE: Rental inspections for Units B c& C, 873 Craigville Beach Road Dear Mr. McKean: We are in receipt of the notices dated July 20,2007, summarizing the results of the inspections conducted on July 19, 2007,by Meredith Morgan for the addresses identified above and have taken action as follows: CMR 170-10: Additional alarms have been installed as instructed by inspecting officer. CMR 410.503: A contract has been executed with a home repair/improvement service to conform with this requirement by installing balusters 4.5" apart as opposed to the existing 6" span. With regard to this last correction,we request that the date for full completion be extended from the thirty(30) days identified in your notice until September 18, 2007, an additional twenty(20) days. We solicited several repair agencies for immediate action and were not successful in engaging a firm guarantee for completion prior to this date. Respectfully submitted, Martin C. Traywick Rental Agent for Marina nning Certified Mail#7003 1680 0004 5458 5033 P,�jT�yti Town of Barnstable Regulatory Services + IIARNnABLE. 9� A g Thomas F. Geiler, Director Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 July 20, 2007 Marina Fanning 1120 S. 18th Street Arlington, VA 22202 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY CODE II— MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE CODE CHAPTER 170. The property owned by you located at 873 Craigville Beach Road Unit B, was inspected on July 19, 2007 by Meredith Morgan, Health Inspector for the Town of Barnstable. This inspection was conducted on the basis of the rental registration in accordance with Chapter 170 of the Town of Barnstable Code. The following violations of the State Sanitary Code were observed: 105 CMR 410.503 —Protective Railings and Walls. Balusters observed to be 6" apart. The following violations of the Town of Barnstable Code were observed: 1� 70-10—Smoke Detectors and Carbon Monoxide Alarms. No CO alarms provided on first or second floor. You are directed to correct the violations listed above within twenty-four (24) hours of your receipt of this notice by installing CO detectors within ten feet of bedrooms on every habitable level in accordance with Mass State Fire Codes. You are directed to correct the violations listed above within thirty (30) days of your receipt of this notice by installing balusters that are no more then 4 '/2" apart. QAOrder letters\Housing violations\Rental ordinance\873B Craigville Beach Road.doc You may request a hearing before the Board of Health if written petition requesting same is received within ten (10) days after the date the order is served. Non-compliance will result in a fine of $100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation. Should you have any questions regarding the above violations, please contact the Town Health Division and ask to speak with the inspector who performed the inspection. PER ORDER OF THE OARD OF HEALTH omX ea , R.S., CHO Director of Public Health Town of Barnstable Cc: Meredith Morgan, Health Inspector Craigville Realty Co., Owner's Representative COMM Fire Department Q:\Order lettersTousing violations\Rental ordinance\873B Craigville Beach Road.doc Certified Mail#7003 1680 0004 5458 5040 P��sttat,,o Town of Barnstable Regulatory Services + BARN STABLE. 9 MA & Thomas F. Geiler, Director Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 July 20, 2007 Marina Fanning 1120 S. 18th Street Arlington, VA 22202 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY CODE II —MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE CODE CHAPTER 170. The property owned by you located at 873 Craigville Beach Road Unit C, was inspected on July 19, 2007 by Meredith Morgan,Health Inspector for the Town of Barnstable. This inspection was conducted on the basis of the rental registration in accordance with Chapter 170 of the Town of Barnstable Code. The following violations of the State Sanitary Code were observed: 105 CMR 410.503 —Protective Railings and Walls. Balusters observed.to be 6" apart. The following violations of the Town of Barnstable Code were observed: 170-10— Smoke Detectors and Carbon Monoxide Alarms. No CO alarms provided on first or second floor. You are directed to correct the violations listed above within twenty-four (24) hours of your receipt of this notice by installing CO detectors within ten feet of bedrooms on every habitable level in accordance with Mass State Fire Codes. You are directed to correct the violations listed above within thirty (30) days of your receipt of this notice by installing balusters that are no more then 4 1/z" apart. Q:\Order letters\Housing violations\Rental ordinance\873C Craigville Beach Road.doc You may request a hearing before the Board of Health if written petition requesting same is received within ten (10) days after the date the order is served. Non-compliance will result in a fine of $100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation. Should you have any questions regarding the above violations, please contact the Town Health Division and ask to speak with the inspector who performed the inspection. a MR.S., CHO BOARD OF HEALTH Director of Public Health Town of Barnstable Cc: Meredith Morgan, Health Inspector Craigville Realty Co., Owner's Representative COMM Fire Department QAOrder letters\Housing violations\Rental ordinance\873C Craigville Beach Road.doc 1 i TOWN OF BARNSTABLE LOCATION C JEez vV SEWAGE # VILLAGE `,-)3 CPVV v t ( (E &AL ASSESSOR'S MV&LOT INSTALLER'S NAME&PHONE NO. W45 RB h('J Sd/`l SEPTIC TANK CAPACITY ! 5 o C, LEACHING FACILITY: (type) e1gLa (size) IL 3 f 5 k)W- ly,c?F NO.OF BEDROOMS 'I BUILDER OR OWNER 1 PERMIT DATE: gT g COMPLIANCE DATE: $�Y S 15 S Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet I Furnished by �+��S�'c vJ� � t3 �AL ;s��wc, ��cl� as �' 39, I._d � � y2r � -` `•.�. i i I COMMONWEALTH OF MASSACHUSETTS ` EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON. MA 02108 617-292-5500 WILLIAM F.VELD TRUDY CORE Governor Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Governor SUBSURF>AC >$EWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A ' CERTIFICATION 873 Craigville- Beach Rd, Unit A Property Address: Centerville, MA Address of Owner: Francis Driscoll Date of Inspection: j- -10 `4 &5 (If different) 127 Fitch Hill Ave Name of Inspector: Wm E Robinson Sr Fitchburg, MA 01 420 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: Wm E Robinson Septic Service Mailing Address: PO Box 1 089, Centervi 1 1 a r MA 02632 Telephone NumberY r 308; 7 7 5—FI 7 6 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: asses S p 3 _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: V Date: (5— The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has;.'design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office ofi,11i'e`Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, aqd ;he approving authority. 1 INSPECTION SUMMARY: Check A, 8, �, or D: A] SYSTEM PASSES: AI have not found any information which indicates that the system violates any of the failure criteria as defined in 31.0 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] YSTEM 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. I icate 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, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection;or the septic tank, whether or not metal, is 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. •,,;�Sri 4) (revised 04/25/97) '.,f Page 1 of 10 • Lv DER on the World Wide Web: http:IMrww.magnet.state.ma.us/dep ej Printed on Recycled Paper • ,: �r SUBSU&FACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 873 Craigville Bch Rd, Unit A, Centerville Owner: Driscoll Date of Inspection:)--X'S — 4 B] S STEM 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). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval'of the Board of Health): broken pipe(s) are replaced obstruction is removed C] FURTHER E ALUATION IS REQUIRED'4kB THE BOARD OF HEALTH: r Ju Condi ions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the publi health, safety and the environment. 1),?;'`SY REM-"WLLL,PASi UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER ICH WILL PROTECTYTHE 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) SYST M WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE YSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVI ONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS 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. Method used to determine distance (approximation not valid). 3) OT ER 4, (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 873 Craigville Bch Rd, Unit A, Centerville. Owner: Driscoll Date of Inspection: :2:—Xo—` Z— D] STEM FAILS: You m t indicate eir,er "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis or this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct he failure. Yes o Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LA GE SYSTEM FAILS: You m st indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: he system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to ublic health and safety and the environment because one or more of the following conditions exist: Yes 0 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 own r or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirem nts of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 873 Craigville Bch Rd, Unit A, Centerville Owner: Driscoll Date of Inspection: ;2--bt 0 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No _ Pumping information was provided by the owner, occupant, or Board of Health. _✓ _ 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. ✓/ _ As built plans have been obtained and examined. Note if they are not available with N/A. t/ _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. 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. The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of l/ Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)] (revised 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 873 Craigville Bch Rd, Unit A, Centerville Owner: Driscoll Date of Inspection: i RESIDENTIAL: FLOW CONDITIONS Design flow:-TYO g.p,d./bedroom for S.A.S. Number of bedrooms:-V—�� Number of current residents: Garbage grinder (yes or no):�i o Laundry connected to system (yes or no)GSJL 5 Seasonal use (yes or no) � Water meter readings, if available (last two (2) year usage (gpd): 1996 — 20 , 000g Sump Pump (yes or no):/tc) 1997 — 12, 000g Last date of occupancy: COM ERCIAUINDUSTRIAL: Type of stablishment: Design fl w: gallons/day Grease tra present: (yes or no)_ Industrial aste Holding Tank present: (yes or no)_ Non-sani ary waste discharged to the Title 5 system: (yes or no)_ Water I eter readings, if available: Last d e of occupancy: OTHER (Describe) Last da . occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)IL o If yes, volume pumped: gallons Reason for pumping: TYPE OF 5YSTEM ___!..:'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) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: S. Sewage odors detected when arriving at the site: (yes or no)&v (revised 04/25/97) Page 5 of 10 C SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 873 Craigville Bch Rd, Unit A, Centerville Owner: Driscoll Date of Inspection: ,IL�01� B LDING SEWER: (Lo to on site plan) Dept below grade: Mater I of construction: _cast iron _40 PVC _other (explain) Dista ce from private water supply well or suction line Dia eter Co ments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:V (locate on �ito plan) 1 Depth below grade: Material of construction: oncrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions:z+ l Sludge depth: / It �. Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: O + ' Distance from top of scum to top of outlet tee or baffle: + Distance from bottom of scum to bottom of outlet tee or baffle: II_L How dimensions were determined: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth ofliquid level in r latio Ito outlet invert, structural integrity evidence of leakage, etc.) ��1 � � GRE E TRAP: (locate on site plan) Depth b low grade: Material f construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensi ns: Scum thi kness: 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 ast pumping: Comm ts: (recomm ndation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, vidence of leakage, etc.) (revised 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 873 Craigville Bch Rd, Unit A, Centerville Owner: Driscoll Date of Inspection: �_02 e, ^ 9 9— TICHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (Iota on site plan) Depth below grade: Materi I of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimen ions: Capaci gallons Design low: gallons/day Alarm I vel: Alarm in working order_ Yes; _ No Date o previous pumping: Comm nts: (condi ion of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: IX (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) Ql PUMP HAMBER:_ (locate n site plan) Pumps i working order: (Yes or No) Alarms n working order (Yes or No) Comm nts: (note ondition of pump chamber, condition of pumps and appurtenances, etc.) (revised 04/25/97) Page 7 of 10 y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 873 Craigville Bch Rd, Unit A, Centerville Owner: Driscoll Date of Inspection: ), -A a- q SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number: leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, C.) 310 Al y-Gc/ < C7 6( y 6/ CESS OOLS: _ (locate on site plan) Numbe and configuration: Depth-t p of liquid to inlet invert: Depth f solids layer: Depth f scum layer: Dimens ons of cesspool: Materia of construction: Indicatio of groundwater: i `.low (cesspool must be pumped as part of inspection) Comments (note cond tion of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate o site plan) Materials construction: Dimensions: Depth of s ids _ Comments: (note Condit on of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 873 Craigville Bch Rd, Unit A, Centerville Owner: Driscoll Date of Inspection: .7, —p2 e —C� i SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) (26v� --------------------- 1 � jy) 3 ; S ? u r (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 873 Craigville Bch Rd, Unit A, Centerville Owner: Driscoll Date of Inspection: —ozo�9 Depth to Groundwater 1' Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) A/' 9 S" (revised 04/25/97) Page 10 of 10