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AMAIN STREET
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OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A 5 h
CERTIFICATION �10
MAP 169 PAR 023
Property Address: 25 DONEGAL CIRCLE
CENTERVILLE,MA 02632
Owner's Name: SULLIVAN,LAWRENCE
Owner's Address: 22 LIBERTY ROAD
HINGHAM,MA 02043
Date of Inspection OCTOBER 24,2002
Name of Inspector:(please print) JAMES D.SEARS
Company Name: A&B Canco
Mailing Address: 350 Main Street
West Yarmouth,MA 02673
Telephone Number: 508-775-2800
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
./ Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: "/Q -,09
The system inspector shall sub/it a c�y ,ection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd
or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.
The original should be sent to the system owner and copies sent tot he buyer,if applicable,and the approving authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that time.
This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 1
f -
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 25 DONEGAL CIRCLE
CENTERVILLE,MA 02632
Owner: SULLIVAN,LAWRENCE
Date of Inspection: OCTOBER 24,2002
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes: ✓
I have not found any infonnation which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes: N/A
One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.
The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"
please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,
exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing
tank is replaced with complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval
of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health)"
broken pipe(s)are replaced
obstruction is removed
ND explain:
Title 5 Inspection Form 6/15/2000 2
Page 3 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 25 DONEGAL CIRCLE
CENTERVILLE,MA 02632
Owner: SULLIVAN,LAWRENCE
Date of Inspection: OCTOBER 24,2002
C. Further Evaluation is Required by the Board of Health: N/A
Conditions exist which require further evaluation by the Board of Health in order to detennine if the system is
failing to protect public health,safety,or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of 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 detennine distance
**This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility
and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided
that no other failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
Title 5 Inspection Form 6/15/2000 3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 25 DONEGAL CIRCLE
CENTERVILLE,MA 02632
Owner: SULLIVAN,LAWRENCE
Date of Inspection: OCTOBER 24,2002
D. System Failure Criteria applicable to all systems: N/A
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
N/A Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in pit 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
N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a
surface water supply
N/A Any portion of a cesspool or privy is within a Zone 1 of a public well
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well
N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. (This system passes if the well water
analysis performed at a DEP certified laboratory,for coliform bacteria and volatile organic
compounds indicates that the well is free from pollution from that facility and the presence of
ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.)
NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact
the Board of Health to detenmine what will be necessary to correct the failure.
E. Large Systems: N/A
To be considered a large system the system must service a facility with a design flow of 10,000 gpd to
15,000 gpd.
You must indicate either"yes"or"no to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is 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 11 of a public water supply well.
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system is failed. The owner or operator of any large system considered a significant
threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The
system owner should contact the appropriate regional office of the Department.
Title 5 Inspection Form 6/15/2000 4
Page 5 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 25 DONEGAL CIRCLE
CENTERVILLE,MA 02632
Owner: SULLIVAN,LAWRENCE
Date of Inspection: OCTOBER 24,2002
Check if the following have been done. You must indicate"yes"or"no"as to each of the following
Yes No
✓ Pumping information was provided by the owner,occupant,or Board of Health
✓ Were any of the system components pumped out in the previous two weeks?
✓ Has the system received normal flows in the previous two week period?
✓ 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)has been determined based on:
Yes No
✓ Existing information. For example,a plan at the Board of Health.
✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable)[310 CMR 15.302(3)(b)]
Title 5 Inspection Form 6/15/2000 5
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 25 DONEGAL CIRCLE
CENTERVILLE,MA 02632
Owner: SULLIVAN,LAWRENCE
Date of Inspection: OCTOBER 24,2002
FLOW CONDITIONS
RESIDENTIAL
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
Number of current residents: N/A
Does residence have a garbage grinder(yes or no): ' NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): YES
Seasonal use(yes or no): YES
Water meter readings,if available(last 2 years usage(gpd)): 2001 21,000/2002 3,000
Sump pump(yes or no) NO
Last date of occupancy: PRESENT
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CM 15.203):
Basis of design flow(seats/persons/sqft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: N/A
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: gallons—How was quantity pumped detennined?
Reason for pupping:
TYPE OF SYSTEM
✓ Septic tank,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 copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
UNKNOWN
Were sewage odors detected when arriving at the site(yes or no): NO
I
Title 5 Inspection Form 6/15/2000 6
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 25 DONEGAL CIRCLE
CENTERVILLE,MA 02632
Owner: SULLIVAN,LAWRENCE
Date of Inspection: OCTOBER 24,2002
BUILDING SEWER(locate on site plan): ✓
Depth below grade: 12"
Materials of construction: ✓ Cast iron _ 40 PVC _ other(explain)
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK(locate onsite plan): ✓
Depth below grade: 18"
Material of construction: ✓ concrete metal fiberglass polyethylene
_ other(explain)
If tank is metal list age: Is age continued by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1,000 GALLON PRE CAST
Sludge depth: 2"
Distance from top of sludge to the bottom of outlet tee or baffle: 28"
Scum thickness: F,
Distance from top of scum to top of outlet tee or baffle: 12"
Distance from bottom of scum to bottom of outlet tee or baffle: 17"
How were dimensions detennined: ASBUILT AND TAPE
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
MAIN TANK AT WORKING LEVEL. INLET BAFFLE,OUTLET BAFFLE.TANK AT 18"BELOW GRADE
WITH BOTH COVERS AT GRADE.NO SIGN OF OVERLOADING SEEN IN TANK.
GREASE TRAP(located on site plan) N/A
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
Title 5 Inspection Form 6/15/2000 7
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMEN'ICS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 25 DONEGAL CIRCLE
CENTERVILLE,MA 02632
Owner: SULLIVAN,LAWRENCE
Date of Inspection: OCTOBER 24,2002
TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other(explain)
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no)
Alarm level: Alarm in working order(yes or no):
Date of last pumping.
Comments(condition of alarn and float switches,etc.):
DISTRIBUTION BOX: N/A (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.,):
PUMP CHAMBER: N/A (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Title 5 Inspection Form 6/15/2000 8
Page 9 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
• PART C
SYSTEM INFORMATION(continued)
Property Address: 25 DONEGAL CIRCLE
CENTERVILLE,MA 02632
Owner: SULLIVAN,LAWRENCE
Date of Inspection: OCTOBER 24,2002
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 1
leaching chambers,number:
leaching galleries,number
leaching trenches,number,length
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of
vegetation,etc.)
LEACHING IS ONE 1,000 GALLON PRECAST PIT.PIT IS 2' BELOW GRADE WITH COVER AT 6".NO
HIGH STAIN LINE.6"WATER IN PIT.NO SIGN OF OVERLOADING SEEN IN PIT.
CESSPOOLS: N/A (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.):
PRIVY: N/A (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.)
Title 5 Inspection Form 6/15/2000 9
Page 9 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 25 DONEGAL CIRCLE
CENTERVILLE,MA 02632
Owner: SULLIVAN,LAWRENCE
Date of Inspection: OCTOBER 24,2002
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.
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Title 5 Inspection Form 1/11/2000 10
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Page 11 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 25 DONEGAL CIRCLE
CENTERVILLE,MA 02632
Owner: SULLIVAN,LAWRENCE
Date of Inspection: OCTOBER 24,2002
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to groundwater 24+ feet
Please indicate(check)all methods used to detennine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observation 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:
NOTE: HOUSE SITS UP ON HILL. AREA HIGH. G.I.S. 24"+GROUND WATER.
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Title 5 Inspection Form 6/15/2000 11
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TOWN OF BARNSTABLE
LOCATION c2S 2)OAO SEWAGE #
VILLAGE 3T C'�EN.11 ,N)ELF ASSESSOR'S MAP & LOT /G 9- o"
1 A13P tc .R S
R'S NAME&PHONE NO. .� C/9/y SQ 8 •7?S- 8 as
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)NO. OF BEDROOMS
BUILDEROR � -5 f� L iUAN
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1A0 ,F C 4A-
PERMITDATE: C�CE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
R £ A�
COMMON WEN1,11I OF MASSACHUSETTS .
EXECUTIVE OFFICE OF ENVIRONMENTAL, AFFAIRS
=_ = DEPARTMENT OF ENVIRONMENTAL I'RO'1'ECT[ON
C F'- ONE WINTER STREET, BOSTON MA 07109 (617) 292-5500
TRUDY COXF
350 MAIN STREET Secretary
ARGEO PAUL CELLUCCI WEST YARMOUTH, MA DAVID B. STRUHS
Governor w 508-775-2800 Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
MAP 169 PAR 023
PROPERTY ADDRESS: 25 DONEGAL CIRCLE, CENTERVILLE ADDRESS OF OWNER:
DATE OF INSPECTION: AUGUST 10, 2000 - JAMES COTTER
NAME OF INSPECTOR : JAMES D. SEARS
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 9310 CMR 15.000)
COMPANY NAME: A&B Canco
MAILING ADDRESS: 350 Main Street,West Yarmouth,MA 02673
TELEPHONE NUMBER: (508)775-2800
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:
X PASSES
r:<'4 _ CONDITIONALLY PASSES
NEEDS FUR ER EVALUATION BY THE LOCAL APPROVING AUTHORITY
FAILS
INSPECTORS SIGNATURE: DATE: AUGUST 11,2000
The system Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within 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:
SITE OVER ALL PASSES,INSPECTION OF SYSTEM IS BASED ON CONDITION OF SYSTEM AT THE TIME
OF THE INSPECTION.THERE IS NO GUARANTEE ON THE LIFE OF THE SYSTEM.
revised 9/2/98 1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIVICATION (continued)
Property Address: 25 DONEGAL CIRCLE,CENTERVILLE
Owner: COTTER,JAMES
Date of Inspection: AUGUST 10,2000
INSPECTION SUMMARY: Check A,B, C, orD:
A] SYSTEM PASSES: X
I have not ound any information which indicates that the system violates any of the failure criteria as defined in 310 CMR
15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
B SYSTEM CONDITIONALLY PASSES: N/A
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.
Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not)
The septic tank is metal,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 is 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.
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 pa
pass inspection if(with approval of the Board of Health).
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled 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 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 25 DONEGAL CIRCLE, CENTERVILLE
Owner: COTTER,JAMES
Date of Inspection: AUGUST 10,2000
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N/A
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to
protect the public health,safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303
(1)(b)THT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY
AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IFANY)
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
1 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 and is equal to or less than 5 ppm. Method
used to determine distance (approximation not valid).
3) OTHER
revised 9/2/98 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
C Q PART A
CERTIFICATION (continued)
Property Address: 25 DONEGAL CIRCLE,CENTERVILLE
Owner: COTTER, JAMES
Date of Inspection: AUGUST 10,2000
D]SYSTEM FAILS: N/A
1
You must indicate either"Yes"or"No" to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR
16.303. The basis for this determination is identified below. The Board of Health should be contacted to S�
Determine what will be necessary to correct the failure.
sO q
Yes No
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 over-
loaded 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'%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. ,a
Any portion of a cesspool or privy is within 100 feet of 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: N/A
You must indicate either"Yes"or"No"as to each of the following: " 4
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
mapped Zone II of a public water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local
regional office of the Department for further information.
i
rgFtsed 9/2/98 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
'Property Address: 25 DONEGAL CIRCLE, CENTERVILLE
Owner: COTTER,JAMES
Date of Inspection: AUGUST 10,2000
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health.
X None of the system components have been pumped for at least two weeks and the system
has not 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.
N/A As built plans have been obtained and examined. Note if they are not available with N/A.
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout.
X All system components,including the Soil Absorption System,have been located on the site.
X 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:
X Existing information.Ex. Plan at B.O.H.
X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation
of distance is unacceptable)11 5.302(3)(b))
X The facility owner(and occupants,if different from owner)were provided with information on ,
the proper maintenance of Sub-Surface Disposal System.
revised 9/2/98 5
A
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 25 DONEGAL CIRCLE, CENTERVILLE
Owner: COTTER,JAMES
Date of Inspection: AUGUST 10,2000
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 220 g.p.d./bedroom for S.A.S.
Number of bedrooms(design) 2 Number of bedrooms(actual): 2
Total DESIGN flow
Number of current residents: 2
Garbage grinder(yes or no): NO
Laundry(separate system) (yes or no): NO If yes,separate inspection required
Laundry system inspected(yes or no): YES
Seasonal use(yes or no) NO
Water meter readings,if available(last two(2)year usage(gpd): 1999 2,000/1998 1,000
Sump Pump(yes or no): NO
Last date of occupancy: N/A
COM M ERCIAUINDUSTRIAL:
Type of establishment:
Design flow: Gpd(Based on 16.203)
Basis of design flow
Grease trap present:(yes or no):
Industrial Waste Holding Tank present:(yes or no)
Non-sanitary waste discharged to the Title 5 system:(yes or no)
Water meter readings,if available:
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPIN�RECORDS and source of information:
N/A
System pumped as part of inspection:(yes or no)
If yes,volume pumped: gallons
Reason for pumping
TYPE OF SYSTEM
X Septic tankisoil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
I/A Technology etc.Attach copy of up to date operation and maintenance contract. e
Tight Tank °o Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information:
UNKNOWN
Sewage odors detected when arriving at the site:(yes or no) NO
revised 9/2/98 6
°
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 25 DONEGAL CIRCLE,CENTERVILLE
Owner: COTTER,JAMES
Date of Inspection: AUGUST 10,2000
BUILDING SEWER: N/A
(Locate on site plan) `
Depth below grade:
Material of construction _ cast iron _ 40 PVC _ other(explain)
Distance from private water supply well or suction line
Diameter
Comments:(condition of joints,venting,evidence of leakage,etc.)
SEPTIC TANK: X
(Locate on site plan) °
Depth below grade: 18"
Material of construction X concrete _ metal _ Fiberglass _ Polyethylene _ other(explain)
If tank is metal,list age Is age confirmed by Certificate of Compliance (Yes/No)
Dimensions: 1,000 GALLON PRECAST
Sludge depth: 4"
Distance from top of sludge to bottom of outlet tee or baffle: 26"
Scum thickness: 3"
Distance from top of scum to top of outlet tee or baffle: 12"
Distance from bottom of scum to bottom of outlet tee or baffle: 15"
How dimension%were determined TAPE
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural
integrity,evidence of leakage,etc.)
MAIN TANK AT WORKING LEVEL,INLET AND OUTLET BAFFLES.TANK 18"BELOW GRADE,COVERS AT GRADE.
GREASE TRAP: N/A
(locate on site plan)
Depth below grade:
Material of construction _ concrete _ metal _ Fiberglass _ Polyethylene _ other(explain)
0
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural
integrity,evidence of leakage,etc.)
revised 9/2/98 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 25 DONEGAL CIRCLE, CENTERVILLE
Owner: COTTER,JAMES
Date of Inspectionb AUGUST 10,2000 Q
TIGHT OR HOLDING TANK: N/A (Tank must be pumped prior to,or at time,of inspection)
(Locate on site plan)
Depth below grade:
Material of construction _ concrete _ metal _ Fiberglass _ Polyethylene _ other(explain)
Dimensions:
Capacity: Gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm in working order Yes; No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX: N/A
(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,)
PUMP CHAMBER: N/A
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
revised 9/2/98 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 25 DONEGAL CIRCLE, CENTERVILLE
Owner: COTTER, JAMES
Date of Inspection: AUGUST 10, 2000
SOIL ABSORPTION SYSTEM (SAS): X
(locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not located, explain: ,
Type:
Leaching pits,number: 1
Leaching chambers,number:
Leaching galleries,number:
Leaching trenches,number,length:
Leaching fields,number,dimensions:
Overflow cesspool,number,
Alternative system:
Name of Technology:
Comments: ® 9 .,
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
ONE(1)1,000 GALLON PRE CAST PIT,PIT DRY. PIT Z BELOW GRADE.COVER 6"BELOW GRADE. NO HIGH STAIN LINE
IN PIT.
CESSPOOLS: N/A
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow(cesspool must be pumped as part of inspection)
Comments::
(note condition of soil,signs of hydraulic failure,,level of ponding,condition of vegetation,etc.)
PRIVY: N/A
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
• revised 9/2/98 9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Addressf?) 25 DONEGAL CIRCLE, CENTERVILLE
Owner: COTTER, JAMES
Date of Inspection: AUGUST 10, 2000
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)
t
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O
revised 9/2/98 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 25 DONEGAL CIRCLE, CENTERVILLE
Owner: COTTER, JAMES
Date of Inspection: AUGUST 10, 2000
NRCS Report name
Soil Type Q a
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Ground water depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to groundwater Feet
Please indicate all the MQ iods used to determine High Groundwater Elevation: cs
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)
NOTE: HOUSE ON HILL, AREA HIGH, NO GROUND WATER PROBLEM.
revised 9/2/98 11
Y
TOWN OF BARNSTABLE
LOCATION 9 5- 2)a 1v e G.#( e SEWAGE #
VILLAGE C T ASSESSOR'S MAP LOT
INBT*ttZR-S NAME & PHONE NO. A & B CANCO 775-6264
SEPTIC TANK CAPACITY C 11,0 A
LEACHING FACILITY:(type) (size)
NO.OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER S
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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