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HomeMy WebLinkAbout0086 CRANBERRY LANE - Health FA CRANBERRY LANE nterville 246 — 182 UPC 12534 No.2-153LOR HASTINGS,MN r Commonwealth of Massachusetts Title 5 Official Inspection Form 11 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -i c !% 86 Cranberry Ln. V Property Address Louis Woolf Owner Owner's Name information is a required for every Centerville Ma. 02632 10-7-20 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 �j, j�-}�0ia:(o filling out forms on the computer, use only the tab Michael Sears key to move your Name of Inspector. cursor-do not Jim The Inspector Man use the return Company Name key. P.O.Box 784 Company Address West Yarmouth Ma. 02673 City/Town State Zip Code 508-364-4398 S114430 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 �aa►ununu„ OF Mas ` s 2. ❑ Conditionally Passes MICHAEL '.N 3. ❑ Needs Further Evaluation by the Local Approving Authority =o SEARS _ No.SI14430 0 4. ❑ Fails / fps.-tl 10-7-20 Inspector's Sign re 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 86 Cranberry Ln. V� Property Address Louis Woolf Owner Owner's Name information is required for every Centerville Ma. 02632 10-7-20 page. City/Town 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 Cesspools 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): I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 i cam, Commonwealth of Massachusetts Title 5 Official Inspection Form �1� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c � 86 Cranberry Ln. u Property Address Louis Woolf Owner Owner's Name information is required for every Centerville Ma. 02632 10-7-20 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): ❑ 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: l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 . Commonwealth of Massachusetts w l'-F Title 5 Official Inspection Form �1� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 86 Cranberry Ln. u Property Address Louis Woolf Owner Owner's Name information is required for every Centerville Ma. 02632 10-7-20 page. City/Town 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 c Commonwealth of Massachusetts �n p Title 5 Official Inspection Form �I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � 86 Cranberry Ln. u Property Address Louis Woolf Owner Owner's Name information is required for every Centerville Ma. '02632 . 10-7-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® , Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 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 CM 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 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 r cam, Commonwealth of Massachusetts �- _ p Title 5 Official Inspection Form r I1; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 86 Cranberry Ln. u� Property Address Louis Woolf Owner Owner's Name information is required for every Centerville Ma. 02632 10-7-20 page. City/Town 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. E] ® 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 c � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � 86 Cranberry Ln. V� Property Address Louis Woolf Owner Owner's Name information is Centerville Ma. 02632 10-7-20 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Description: 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 ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No 2018-15000 gal Water meter readings, if available (last 2 years usage (gpd)): 2019- 11000 gal Detail: Sump pump? ❑ Yes ® No NA Last date of occupancy: Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts �v 6P Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 86 Cranberry Ln. Property Address Louis Woolf Owner Owner's Name information is required for every Centerville Ma. 02632 10-7-20 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: NA Was system pumped as part of the inspection? r ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? .Reason for pumping: t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 C Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 86 Cranberry Ln. V Property Address Louis Woolf Owner Owner's Name information is required for every Centerville Ma. 02632 10-7-20 page. City/Town 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 DER approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 18" Depth below grade: 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 i Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 86 Cranberry Ln. V� Property Address Louis Woolf Owner Owner's Name information is required for every Centerville Ma. 02632 10-7-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. 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) ❑ Yes ❑ No Dimensions: Sludge depth: 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 baffle 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 c Commonwealth of Massachusetts �v p Title 5 Official Inspection Form �1� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 86 Cranberry Ln. u� Property Address Louis Woolf Owner Owner's Name information is required for every Centerville Ma. 02632 10-7-20 page. Cityrrown 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: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official ,Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 86 Cranberry Ln. Property Address Louis Woolf Owner Owner's Name information is required for every Centerville Ma 02632 10-7-20 page. City/Town 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: 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 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.): i t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts �w Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 86 Cranberry Ln. Property Address Louis Woolf Owner Owner's Name information is required for every Centerville Ma. 02632 10-7-20- page. City/Town 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: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): - * 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: 0 leaching pits number: i El leaching chambers number: 0 leaching galleries number: El leaching trenches number, length: leaching fields number, dimensions: ® overflow cesspool number: I ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Iti Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 86 Cranberry Ln. Property Address Louis Woolf Owner Owner's Name information is required for every Centerville Ma. 02632 10-7-20 page. Citylrown 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 is 1 overflow cesspool pool is clean dry and structurally sound with no sign of failure 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 2- main and overflow Depth—top of liquid to inlet invert 4 2"Depth of solids layer 2 Depth of scum layer Dimensions of cesspool 6'x6' Materials of construction Block Indication of groundwater inflow ❑ Yes ® No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Main pool has 2' of water and outlet tee overflow is dry and clean, no stain line t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c � 86 Cranberry Ln. u Property Address Louis Woolf Owner Owner's Name information is required for every Centerville Ma. 02632 10-7-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 86 Cranberry Ln. Property Address Louis Woolf Owner Owner's Name information is required for every Centerville Ma. 02632 10-7-20 page. City/Town 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 flecu shy OF/MASS p'�4 Al Z. MICHAEL a— �,5.q =o. SEARS ' 31n q No.SI14430 .: cn '-.'r' . a-50 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 c Commonwealth of Massachusetts �v Title 5 Official Inspection Form += I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u— 86 Cranberry Ln. Property Address Louis Woolf Owner Owner's Name information is Centerville Ma. 02632 10-7-20 required for every 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: 10' 8"feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ' ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation). ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Hand augured and hit water at.10' 8" - Bottom of overflow is 8' 2' 8" seperation Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 t , Commonwealth of Massachusetts p Title 5 Official Inspection Form �I Subsurface Sewage.Disposal System Form- Not for Voluntary Assessments u 86 Cranberry Ln. Property Address - Louis Woolf Owner Owner's Name information is Centerville Ma. 02632 10-7-20 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% ` �.�-o�, o-� Sf�S I d• so ov�P�j,w 8 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 OMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION OFFICIAL INSPECTION FORM TITLE 5 -NOT FOR SUBSURFACE SEWAGE DISPOSAL SYSTTEY ASSESSMENTS PART A M FORM CERTIFICATION Property Address:6; C f i 1 � � Owner's Name: �� Owner's Address: Date of Inspection: Name of Inspector: 1 ase p nt) Company Name: Mailing Address: p Telephone Number: AA CA-. 0Z(O©I CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and below is true,accurate and complete as of the time of the inspection.The ' that the information reported training and experience is the proper function and maintenance of on site sewage di was Performed based on my approved system inspector pursuant to Section 15.340 of Title 5 310 g disposal systems.I am a DEP CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: C' 3 12v I L The system inspector shall submit a copy of this inspection report to the Approving DEP)within 30 days of completing this inspection.If the system is a shard system or hasa design flow of 10 gpd or greater,the inspector and the system owner shall submit the report to the appropriate ty(Board of Health or DEP.The onthe original should be sent to the system owner and copies sent to the buyeraplicab regional and the app roving ovviin authority. g Notes and Comments tt �� e�eei ��� �ve J�QSd V��� aa This report only describes conditions at the time of inspection and under the condibons o time. This inspection does not address how the system will perform in the future under the sam_e`or different conditions of use. fy'use at thhtz 7 7 > 00 Title 5 fnspection Form 6/15/2000 i .+ page 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSES SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOB TS PART A CERTIFICATION(continued) Property Address: G ����bec L� e t Owner: Date of Inspection: ) °� /2 p 0 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: .�� I have not found any information which indicates that any o f the 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated be described m 310 CMR Comments- 1 1 `�� � c( B. System Conditionally Passes: One or more system componentsrepaired. as described in the"Conditional pass"section need to be replaced or system upon completion of the replacement or repair,as approved by the Board of Health,will pass, Answer yes,no or not determined Y N ND explain, ( )in the for the following statements.If"not de ermined"please The septic tank i ` tan and over 2r years old*or the septic tank(whether me or not)is unsound,exhibits substantial infiltration or exfiltration or tank failure is ' structurally existing tank is replaced with I 0 1 ' imaunent ystem will pass inspection if the *A metal septic tank will ass inspection �pemP Ymg septic tank as approved by the Bo of Health. indicating that the tank is less than 2 h ears old istructurally av l�sound,not le g and if a Certificate of Compliance ND explain: Observation of sewage backup or break out o hi static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or unev approval of Board of Health): s�bution box System will pass inspection if(with broken pip )are replac obstruc ' n is removed distri lion box is leveled or r ced ND explain: The system required p ing more than 4 times a year due to broken or obcted i e s Pass inspection if(with appr al of the Board of Health): t p P ( ) The system will broken pipe(s)are replaced obstruction is removed r ND explain: T;tla i Tnanarfinn T7` -All crnnnn 2 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: Date of Inspection: C. Further Evaluation is Required by the Board of Health: Conditions exist which require fiuther evaluation b the Bo is fuelmil, protect public health,safety or the environment �d of Health in order to determine if the system 1• s9) mwi Y will pass unless Board of Health determines in accordance with 310 � syste is not functioning in a manner which will protect public health,safety th envir(b) dt the h' a enWron ent. _. Ces 1 or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will f\ins Board of Health(and Public Water Supplier,if any)determines that system is Amcdo er that protects the public health,safety the ,l end environment: The system has a septic and soil absorption system(SAS)�d the SAS is within 100 feet of a surface water supply or tributary t a surface water supply. The system has a septic tank and S and the S:s7is ' z*tdbnina, Zone 1 of a public water supply. The system has a septic tank and SAS d the S within SO feet of a private water supply well. The system has a septic tank and SAS ate, SAS is less than 100 feet but SO feet or more from a private water supply well**.Method used t 1dete ' e distance "This system passes if the well water anal sis erf bacteria and volatile organic compounds indicates that the aell is free certified m poll non fr�mothat f coi�ty and the presence of ammonia nitro g and nitrate nitrogen is a to or less than S failure criteria are triggered q copy of the analysis must be a ched to this formp�provided that no other 3. Other: T41a G incnr.rtinn Fnnn 4n ci,)nnn 3 OFFICIAL INSPECTION FORM_ NOT FOR VOL SUBSURFACE SEWAGE DISPOSAL SST UNTARY ASSESSMENTS PART A EM INSPECTION FORM CERTIFICATION(continued) Property Address: 1r Owner: Date of Inspection: D D. System Failure Criteria applicable to all systems: You m s 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 S Discharge or ponding of effluent to the s ground or g8 AS or cesspool clogged SAS or cesspool surface of the surface waters due to an overloaded or Static liquid level in the distribution box above outlet invert due to an Overloaded d or clogged — � Liquid depth in cesspoolgged SAS or is less than 6 below invert or available vol ='L Required pimping more than 4 times in the last year NOT less than'/a day flow Of times pumped _ due to clogged or obstructed plpe(s).N umber Any portion of th Any portion of he e SAS,cesspool Or Privy is below high ground water elevation. water supply. spool or privy is within 100 feet of a surface water supply or tributary to a surface -7 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 Any portion of a cesspool or privy is less than 100 feet but �pP1Y well. supply well with no acceptable water quality analysis. greater than SO feet from a private water Performed at a DEP certified laboratory,for conform bacteria and volatile organic co ounds Y system passes N the wen water analysis, Indicates that the well is free from pollution from that tacW _ nitrogen and nitrate nitrogen is equal to or less than S ty and the presence of a � onla are triggered.A co PPr4 Provided that no other failure criteria py of the analysis must be attached to this form.] (Yes/No)The system fa�i1 .I have determined that o ne described in 310 CMR 15.303, therefore the system of" re of the above failure criteria exist as Health to determine what will be necessaryThe system owner should contact the Board of to correct the. he failure. E�Large Systems: To b considered a large system the system must serve a facility with a mod' design flow of 10,000 gpd to 15 00 You must in "cafe either"yes"or no"to each of the following; (The following crite ." ply to large systems in addition to the criteria'above) Yes no. — the system is within 400 feet f surface drinking water suppl the system is within 200 feet of a tributary a surf drinking water supply the system is located in a nitrogen sensi - e area(Irate ' Wellhead Protection Area-ly�rpA Zone H of a public water supply w )or a mapped If You have answered"yes"to an estion in Section E the system is consid "Yes"in Section D above the ere significant threat under 8e sYstem has failed. The owner or operator of an far ficant threat, or answered ction E or failed under Section D shall u y g stem considered a 15.304.The syste er should contact the appropriate regional office the s s em m acco cc with 310 CMR epartment. Title fnonnrtinn Fnr.M 6/1;/7nnn 4 t OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY AS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FONTS PART B FORM CHECKLIST Property Address: �IL4 Owner: Date of Inspection• p Check if the following have been done.You must indicate"Yes"or"no"as to each of the folio wm Yes No PumPing infomution 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 is 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 of the baffles or tees,material of construction,dimensions,depth of li tank inspected for the condition quid,depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information o maintenance of subsurface sewage disposal systems? a the proper The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yet no j 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 is unacceptable)[310 CMR 15.302(3)(b)] of distance TiNn i incnni f�nn 17—m A/1 ai,)nnn 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT'S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: j r r, b — � Owner: C Date of Inspection: RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design): Number of bedrooms(actual): 2 DESIGN flow based on 310 CUR 15.203(for example: 110 gpd x#of bedrooms): 2 Z Number of current residents: 0 Does residence have a garbage grinder(yes or no):K 6 Is laundry on a separate sewage system(yes or� no):1 [if yes separate inspection required Laundry system inspected(yes or no): � ] Seasonal use:(yes or no): Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no):�p Last date of occupancy; ©$ r COMMERCUL/INDUSTRIAL, Type o establishment: Design flo seed on 310 CUR 15.203): Basis of design (seaPers0n s/sgft,etc. i' Grease trap present(ye -or no): d Inus 1 trial waste holding tank pies no Non-sanitary waste dischar e e Ti 5 tern(yes or no):_ Water meter readin s ' vailable: Last date of o ancy/use: O R(describe): Pumping Records GENERAL INFORMATION Source of information: �,i N,0—VI— Was system pumped as part of the ins ction(Yes or no):2�p If yes,volume � pumped: gallons—How was quantity pumped determined? Reason for pumping: T�TE 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 components,date installed(if known)and source of information: C� W ("'s Were sewage odors detected when arriving at the site(yes or no): h8 T41a Tnc.+n�ttnn >+,,,,,,4i1 Aqi,7nnn 6 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS PART C SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM SYSTEM INFORMATION(continued) Property Address: Owner: 'lnJ © 00 Date of Inspection: Z O� BUILDING SEWER(locate on site plan) Depth below cr ' grade: Materials of construction:jc-�ast iron —Z40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on c 'tion o joints,venting,evidence of leakage,eta,): o SEPTIC TANK:—(locate on site plan) Depth below grade: -0-] " Material of construction: fConcrete--nletal_fiberglass__polyethylene ­other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Co certificate) mPe(yes or no):_(attach a copy of Dimensions: Sludge depth: Z Distance from top of sludge to botttoom of outlet tee or baffle: 7j a Pr Scum thickness: • G��C.'VeS I Distance from top of scum to top of outlet tee or baffle: '3 Distance from bottom of scum to bottom of outlet ee or baffle: —(p r' 7 © `� , r��e- S How were dimensions determined: 3"�h Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural irate as related outlet invert,evidence of leakage,etc J: gnhr,liquid levels ASE TRAP:—(locate on site plan) Depth below e: Material of construction. concrete metal_fiberglass_pp yethylene other (explain): --' _ Dimensions: Scum thickness: Distance from top of sc m of to outlet tee or baffle: Distance from bottom of s to bottom of outlet tee or baffle: Date of last pump' Comments(o limping recommendations,inlet and outlet tee or baffle condition, ctural inte as relate o outlet invert,evidence of leakage,etc.): grity,liquid levels Title C fncnnntinn Rnrm lit VIAnn 7 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: a Lh Owner: Date of Inspection: Z 6 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) DePthbelo_ggrade: Material of construction: concrete metal fiberglass___polyethylene other(expl in); Dimensions: Capacity. gallons Design Flow: allons/day Alarm present(yes or no): Alarm level: Alarm in working order ast __ (yes or no): Date of l PumPin6: Comments(condition of al .and-float switches,etc.): DISTRIBUTION BOX: (ifpresent 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.): rv` e` P CHAMBER: (locate on site plan) Pumps in working order_(yes or no): Alarms in working or (yes or no):-- Comments(note condition of PAP chamnbft con. 'tion of pumps and aP_purtenancesete�: — Title i fnanortinn Rnrn (if�i�nnn 8 OFFICIAL INSPECTION FORM—NOT FOR VOLUNT 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION S FORM PART C SYSTEM INFORMATION(continued) Property Address: , (. Y\b Lr\ Owner: 0 �I k �— Date of Inspection: Z 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: overflow cesspool,number: j innovative/alternative system Comments(note condition of so' si Type/name ofhnology: etc.): d' °f hydraulic failure,level of ponding,damp soil,condition of vegetation, f o 1 -P c�e CESSPOOLS: (cesspool must be Pumped as part of inspection)(locate on site plan) Number.and configuration: Depth—to of liquid to inlet invert: Depth of solidsilayer: Depth of scum layers Dimensions of cesspool: Materials of construction: Indication of groundwater inflow Comments(note condition of so' (signs �,� • hydraulic failure,level of ponding, condition of vegetation'etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of s , signs of hydraulic failure,level of ponding,condition o vegetation, etc.): Title i incnni.tinn T7nnrn�/i�/�nnn 9 Page 10 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOi.UNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ,Co ('7Ar\V)zf la Owner. Date of Inspection: 6" 12 0 (L) 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. ID b� arect � 0CL 2-5 ` Qo2- L4%P ti 14 in OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: L1)0\-t- o Date of Inspection: (') 3 T 2 o 10 6 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water -At feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: 2cj '200c- 0L Y u must describe how you established the hi h ground water elevation: v v `r' e- v ce A v GroA WoA--�-r +bv rd o-Jey- 2-F - 4;r\_ below by-5� Tilla C Tnena-inn 17— /.ii aiinnn 11 I ` CO'.%MON-%VE.*ALTH OF MASSACHLSETTS EXECUTIVE OFFICE OF ENNMO, IE\TAI. AFF.AIP.S F _ DEPARTMENT OF ENVIRONMENTAL PROTECTION O\T UL-M STREE':. BOS, \hi.OA 0210� t61"j 242-551w TRUDY COX-7 Secreta_-.v ARGEO PALL CELLL CCi 1 DAVID B STp-uS _ Governor Cotnsttus:onec SUBSURFACE SEWAGE DISPOSAL SYSTEM Mt1SPECTWN FORM PART A CERYPWATION Property Address: 86 Cranberry Lane Name of Otrr wZ ;n K' aber W. annisport Address of Otrrtar Date of Inspection: 7-1 Name of inspector:(Please Primp Vim. E. Robinson S r. I am a DEP approved s 16M inspector to Section 15-340 of Title S(310 CUR 15.000i Company Marne: V E . Robinson Septic Service 1VI sang Address: PO Box 0 9. Cent ery ille MA Telephone Number: CERTIFICATION STATEMENT I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails A) � Inspector's Signature: 6 I Date: —a--6 The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEPlwithin thirty (30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable, and the approving authority. NOTES AND COMMENTS C ra��U fop 4, re1viSe0 9/2/98 Pape Iof11 as Z: -•._lei o-Rec%c;rc'Pam, i. SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM PART A CERTIFICATION leontinued) Nvp"Address:86 Cranberry Lane , W. Hyannisport *)wner: K iub e r Date of Inspection: 7 WSPECTION SUMMARY: Check (C B, C, of D: A. SYS PASSES: 1 heve not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. S STEM CONDITIONALLY PASSES: ne'or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system.upon ompletion of the replacement or repair,as approved by the Board of Health,will pass. Indicate y s,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 lattached)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 complying septic tank as approved by the Board of Health. _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed revised 9/2/98 Page 2of11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Icontramd) Property Address: 86 Cranberry Lane , W. Hyannisport Owner- Kiuber Dace of Inspection: 7_,a d,..4 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 the public health, safety and the environment. I SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE WITH 310 CMIR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2 SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 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). 1 OTHER rci;-se: P2ge3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 86 Cranberry Lane , W. Hyannisport Owner: Kluber Date of Inspection:?,-i o"��yu D. SY TEM FAILS: You must'ndicate either "Yes" or "No" to each of the following: 1 ave determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this d termination is identified below. The Board of Health should be contacted to determine what will be necessary to correct.the failure. Yes N Backup of sewage into facility-or system component due to an overloaded orelogged 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 112 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. LARGE SYSTEM FAILS: You ust indicate either "Yes' or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA) or a mapped Zone II of a public water supply well) Th owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional o ce of the Department for further information. _"wised 9 2/9b Pagc4of11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM, PART B CHECKLIST Prop"Address: 86 Cranberry Lane , W. Hyannisport Owner: Kiuber Date of Inspection: .7,_1;Z_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►eceiving 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. _ 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: _ Existing information. For example, Plan at B.O.N. A/ _ Determined in the field(if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) / f15.302(3)(b)] V _ The facility owner (and occupants,if differeru from owner) were provided with information on the properxnaintanaaca of SubSurface Disposal Systems, re ise6 o Page 5 of I1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ' SYSTEM INFORMATION '►operty Address:86 Cranberry Lane , W. Hyannisport Owner:. K i ub e r Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: JCO g.p.d./bedroom. Number of bedrooms(design): Number of bedrooms lactunl)3 Total DESIGN flow-36"0 Number of current residents: a Garbage grinder(yes or no): T-v Laundry(separate system) lyes or no)A-0; If yes, separate inspection required Laundry system inspected (y�s or no; Seasonal use lyes or no):Water meter readings, if available (last two year's usage(gpd): 1999 57, 000 gal. Sump Pump(yes or no):�V 199 ga r Last date of occupancy:` •-IP--O-<-) C MERCIAL/INDUSTRIAL: ,Type f establishment: Desig flow: apd ( Based on 15.203) Basis f design flow Greas trap present: (yes or no)_ Indust al Waste Holding Tank present: (yes or no)_ Non-s nitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last ate of occupancy: OTH :(Describe) Last ate of occupancy: GENERAL INFORMATION PUMPING RECORDS source of information: System pump d as part of inspection: (yes or no) If yes, volume pumped: 3'6-0 gallons P— Reason for pumping: -t' TYPE OF SYSTEM Septic tank%distribution boxisoil absorption system —�}/Single cesspool `� Overflow cesspool Privy Shared system lyes or no) (if yes, attach previous inspection records;if any) ' IIA Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other A APPROXIMATE AGE of all components, date installed(if known) and source of information: 6 (� y-•n S �/�ciC's Sewage odors detected when arriving at the site: (ye's 0"r,no)'&--0 ..rLsei G �G re a /�; Page 6(if il i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Icontimiod) ►►operty Address:86 Cranberry Lane , W. Hyannisport Owner: Kiuber Date of Inspection: B DING SEWER: (Loc to on site plan) Depth below grade:_ Maten I of construction:_cast iron_40 PVC_ other(explain) Distan a from private water supply well or suction line Diamet r Comme its: (condition of joints, venting. evidence of leakage,etc.) SEPTIC TANK:— (locate n site plan) Depth elow grade:_ Materi I of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) If tan is metal,list age_ Is.age confirmed by Certificate of Compliance_(Yes/No) Dimen ions: Sludge depth: Distanc from top of sludge to bottom of outlet tee or baffle: Scum t ickness: Distanc from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How dim nsions were determined: �omment Irecomm dation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence f leakage, etc.) GREASE RAP: (locate o site plan) Depth elow grade:_ Materi I of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) Dimensi ns: Scum thi kness: Distance rom top of scum to top of outlet tee or baffle: Distance om bottom of scum to bottom of outlet tee or baffle: Date of la t pumping: Comment (recomm dation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence f leakage, etc.) revi-se PaRe7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'toperty Address: 86 Cranberry' Lane , W. Hyannisport Owner: Kiuber Date of inspection: T1G OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate n site plan) Depth be w grade:_ Material o construction:_concrete_metal_Fiberglass_Polyethylene_otherlexplain) Dimensions. Capacity: gallons Design flow: gallons/day Alarm presen Alarm level: Alarm in working order: Yes_ No Date of previ us pumping: Comments: (condition of i let tee, condition of alarm and float switches, etc.) DISTRIBU ON BOX:_ (locate o site plan) Depth of i quid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAN BER: (locate on si a plan) Pumps in w rking order: (Yes or No) Alarms in orking order (Yes or No) Comment (note co ition of pump chamber, condition of pumps and appurtenances, etc.) reviseZ. 9/2 !9c Page 8ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(coftnued) 'roperty Address:86 Cranberry Lane , W. Hyannisport. Owner: K lub e?r , Date of Inspection: ., SOIL ABSORPTION SYSTEM(SAS): (locate on site Ian, if possible;excavation n P P of required,location may be approximated by non-intrusive methods) - If not located, explain: Type: leaching pits, number:_ leaching chambers,number:_ eaching galleries, number:_ eaching trenches, number, length: I aching fields, number, dimensions: verflow cesspool, number,_ Itemative system: Name of Technology: Comment Inote cond tion of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: G•-7 I )epth of scum layer: — J ' Dimensions of cesspool: I W Materials of construction: d C' S Indication of groundwater: d inflow (cesspool must be ✓ l'P pumped as part of inspection)�7r �d Y ti 0 A., Comments: (note condition of soil, signs of hydraulic failure, level f ponding, condi7 on of vegetation, etc.) , ® O PRI _ (locat on site plan) Maier als of construction: Dimensions: Dept of solids: Co ments: (no condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) c= G - �' '/ PaRc 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ` SYSTEM INFORMATION(continued) Noperty Address: 86 Cranberry Lane , W. Hyannisport '"'r1e` K iub e r Date of Inspection: _�nr��.•� SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 04 re -iset Pap.10 0(11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART C SYSTEM INFORMATION(ccnt-ed) ropertyAddress-- 86 Cranberry Lane , W. Hyannisport Owner: K iub e r Date of Inapeetion: NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Moderate Deep Groundwater depth: Shallow SITE EXAM Slope Surface water Check Cellar Shallow wells y Estimated Depth to Groundwater 5 Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record t Observed Site (Abutting property,observation hole. basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Y I revised 5/2/5E Page 11of11 a _ TOWN OF BARNSTABLE LOCATION b �Y� SEWAGE# SfVILLAGE(JO V/1 t`i^ i Vt.4e, ASSESSOR'S MAP&PARCEL NAME&PHONE NO. �b.e� SEPTIC TANK CAPACITY [0O0 jet-A ' LEACHING FACILITY:(type) C , NO.OF BEDROOMS _ OWNER '�L()tJ D 0 .- �-v�S G.C� Otrl PERMIT DATE: DATE: 0?j ,2-01 06 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 f 'lity) Feet FURNISHED BY V-,e.Ckr Q 2`6ig2' V6I -3tt Al- ,J f1 TOWN OF B.ARNSTABLE LOCATION LA-pj& SEWAGE[#� tLLAGE W, 4yA -12-7'" ASSESSOR'S MAP & LOT `F Z INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) to NO. OF BEDROOMS 2 PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE .COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No �4 �- Zp Ate^/ '.. I- ' rLN Z`