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HomeMy WebLinkAbout0067 FERNBROOK LANE - Health 67 FERNBROOK LANE, CENTERVILLE A= lllla �o UPC 12534 ' No.21� 53LOR '4�sr HASTINGS. MN Commonwealth of Massachusetts Title 5 Official Inspection Form r - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Fernbrook Lane 'a - -o Property Address Arthur&Julie Mombourguette A Owner Owner's Name IV information is f MA 02632 J(�f NVCW I LI Zc'�j T required for every Centerville (Barnstable) __ page. City/Town State Zip Code Date of Inspe ion Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information S/# a I r filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not David D. Flaherty Jr RS REHS - use the return Name of Inspector key. Flaherty Environmental Services Company Name P.O. Box 81 Company Address Yarmouth Port MA 02675 City/Town State Zip Code 774-994-1166 _ SI#4713 Telephone Number License Number B. Certification 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 ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspector's Signature Date The system inspector shall su mit 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 should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Forte of Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Fernbrook Lane `J Property Address Arthur&Julie Mombour uette Owner Owner's Name information is Centerville (Barnstable) MA 02632 �5 required for every State Zip Code Date of 1 spection page Cityrrown B. Certification (cont.) 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 of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltrabon 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). Title 5 Official Inspection Form:Subsurface Sewage Disposal system.Page 2 of 57 t5ins.doc-rev.6116 T ' Commonwealth of Massachusetts c-z Title. 5 Official Inspection For m' � Subsurface Sewage Disposal System Form - Not for Voluntary Assessments IM- / 67 Fernbrook Lane Property Address Arthur&Julie Mombourquette Owner Owner's Name information is required for every Centerville (Barnstable) MA 02632 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ 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 pipes) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: 5 ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts -r Title 5 Official Inspection For —`j Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Fernbrook Lane Property Address Arthur&Julie Mombourquette Owner Owner's Name ( information is required for every Centerville (Barnstable) MA 02632 page. Cityrrown State Zip Code Date of In ection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well"*. Method used to determine distance: *' This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is Tess than day flow v R11F; Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Forte Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Fernbrook Lane Property Address Arthur&Julie Mombourquette Owner Owner's Name information is required for every Centerville (Barnstable) _ MA 02632 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal c oliform 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 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system cos significant considered a si nificant 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. -_- ___ [Sins doc•rev 6l1&_- _. Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 5 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Fernbrook Lane Property Address Arthur&Julie Mombour uette Owner Owners Name [ information is Centerville (Barnstable) MA 02632 required for every State Zip Code Date of Inspection page CitylTown C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to.each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of ❑ ® this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? El information the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: 5 Number of bedrooms (design): 5 Number of bedrooms (actual): 550 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 t5ins.doc•rev.6116 Commonwealth of Massachusetts —r Title 5 official Inspection Forte rl Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 67 Fernbrook Lane `J Property Address Arthur&Julie Mombour uette Owner Owners Name information is (Barnstable) MA 02632 1 S required for every Centerville State Zip Code. Dat of In ection page. City/Town D. System Information Description: 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No '16i 208 gpd; '15: Water meter readings, if available (last 2 years usage (gpd)): 647 gpd Detail: extensive irrigation system ❑ ® Sump,pump? Yes No current Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Paae 7 of 17 tsm.doc-rev.6116 Commonwealth of Massachusetts �s Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 00 67 Fernbrook Lane Property Address Arthur& Julie Mombourquette Owner Owner's Name J / �� / information is Centerville (Barnstable) MA 02632 [ / — required for every page. City/Town State Zip Code Date f Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: owner, pumped last year Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank_ Attach a copy of the DEP approval. ❑ Other(describe): Title 5 official Inspection Form:Subsurface Sewage Disposal System.Page 8 of 17 Commonwealth of Massachusetts t;= — Title 5 official Inspection Forte D Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Fernbrook Lane Property Address Arthur& Julie Mombour uette Owner Owner's Name information is S required for every Centerville (Barnstable) MA 02632 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known) and source.of information: 1984 per BBOH Were sewage odors detected when arriving at the site? ❑ Yes ® No- Building Sewer(locate on site plan): 1.5 Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: >30feet Comments (on condition of joints, venting, evidence of leakage, etc.): joints tight, venting through dwelling adequate no evidence of leakage Septic Tank (locate on site plan): 1 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 1500 gallon Dimensions: 4" Sludge depth: t5ins.doc•rev.6116 Title 5 official Inspection Form:subsurface sewage Disposal system•Page 9 of 17 Commonwealth of Massachusetts —0 Title 5 Official inspection Forte Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Fernbrook Lane Property Address Arthur&Julie Mombourquette Owner Owner's Name 1 ��� 7- information is Centerville (Barnstable) MA 02632 required for every State Zip Code Dat of Inspection page Cityrrown D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 30" V, Scum thickness 7„ Distance from top of scum to top of outlet tee or baffle 14" Distance from bottom of scum to bottom of outlet tee or baffle dip stick tape measure 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.): maintenance pumping should be performed every two to three years, inlet&outlet tees in good working order, tank seems structurally sound, liquid level is appropriate no evidence of leakage Grease Trap (locate on site plan): Depth below grade: feet Material of construction: concrete metal fiberglass ❑ polyethylene El other(explain): ❑ ❑ ❑ 9 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 Title 5 official Inspection Forth:Subsurface Sewage Disposal System-Page-10 0`17 t91 c don-rev:6/16 .` Commonwealth of Massachusetts w (p, Title 5 Official Inspection For =i col Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 Fernbrook Lane Property Address Arthur&Julie Mombourquette — Owner Owners Name information is (Barnstable) MA 02632 f? Centerville required for every State Zip Code Date of In ection page City/Town D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete metal fiberglass ❑ polyethylene ❑ other (explain): ❑ ❑ 9 Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 rs \ Commonwealth of Massachusetts Title 5 Official Inspection Firm i=l _— I'�I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .� 67 Fernbrook Lane `r Property Address Arthur&Julie Mombour uette Owner Owner's Name S information is Centerville (Barnstable) MA 02632 required for every State Zip Code Date of Inspection page Cit7y own D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): 0" 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.): dbox seems level, no evidence of leakage Pump Chamber(locate on site plan): ❑ Yes ❑ Now Pumps in working order: ❑ No* Alarms in working order: ❑ Yes 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. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 t5ins.doc•rev.6116 Commonwealth of Massachusetts _ Title 5 official Inspection For a i; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Fernbrook Lane Property Address Arthur&Julie Mombourquette Owner Owner's Name information is Centerville Barnstable) MA 02632 _1 required for every ( page. City/Town State Zip Code Dat of Inspection D. System Information (cost.) 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.): (1)6' x 6' precast leach pit with 3' stone around, no signs of hydraulic failure or breakout, soils sandy with some gravel, vegetation typical dawn) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts w� -r Title 5 Official inspection Form I^� W'= Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Fernbrook Lane `J Property Address Arthur&Julie Mombourguette Owner Owner's Name information is Centerville (Barnstable) MA 02632 !/ required for every State Zip Code atc ui ��Ncc tlul' page City/Town D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 14 of 17 _— __.S5ins.doc•rev.6/16 Commonwealth of Massachusetts R �, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Fernbrook Lane Property Address Arthur&Julie Mombourquette Owner Owner's Name information is Centerville Barnstable MA 02632 /i I 5 required for every page. CityTrown State Zip Code u to of peciion D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately CC 'J II - t ar f 2,q I q01 S "in •rev,6/ 6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form r _ " Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Fernbrook Lane _ Property Address Arthur&Julie Mombourquette Owner Owner's Name information is Centerville Barnstable MA 02632 S� required for every (Barnstable) page. CitylTown State Zip Code D/t�I spection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells >13 Estimated depth to high ground water: 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: 1984Date ❑ 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: deep hole tests performed on 9/4/1984 for septic system design plans indicate no groundwater encountered at 13' verified pond elevation in backyard) — Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins doc•rev.6/16 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form -1 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 Fernbrook Lane Property Address Arthur&Julie Mombourguette Owner Owner's Name /t," information is required for every Centerville (Barnstable) MA 02632 P opage. CityTrown State Zip Code Dates Ion_ E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 4 Commonwealth of Massachusetts _oy�— Title 5 Official Inspection For Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 Fernbrook Lane Property Address Brian DePierre Owner Owner's Name information is Centerville MA 02632 February 2 required for , 2013 every 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 filling out A. General Information forms on the computer,use 1. Inspector: only the tab key to move your David D. Flaherty Jr., R.S. cursor-do not Name of Inspector use the return key. Flaherty Environmental Services YSri�Pa 9 ..,� S „I Company Name P.O. Box 81 Company Address Yarmouth Port MA 02675 City/Town State Zip Code 508-362-1657 S14713 Telephone Number License Number B. Certification 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 ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority February 3, 2013 In ector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will "perform y p rm in the future under the same or different conditions of use. �O V t5ins-06108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 z Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Fernbrook Lane Property Address Brian DePierre Owner Owner's Name information is ry Centerville MA 02632 February 2 2013 required for , every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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 of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than.20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts JD _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 Fernbrook Lane Property Address Brian DePierre Owner Owner's Name information is Centerville MA 02632 February 2 required for , 2013 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a 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 a salt marsh !Sins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 A 1 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Fernbrook Lane Property Address Brian DePierre Owner Owner's Name information is ry Centerville MA 02632 February 2 2013 required for , every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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 aseptic 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 coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ z Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins 09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 67 Fernbrook Lane Property Address Brian DePierre Owner Owners Name information is Centerville MA 02632 February 2 2013 required for , every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is 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 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within.400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply El E 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 If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 T Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 Fernbrook Lane Property Address Brian DePierre Owner Owner's Name information is Centerville MA 02632 February 2 2013 required for ►Y every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® 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. ® 0 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)] D. System Information Residential Flow Conditions: Number of bedrooms(design); 5 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 t5ins.•09L08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Fernbrook Lane Property Address Brian DePierre Owner Owner's Name information is ry Centerville MA 02632 February 2 2013 required for , every page. Cityfrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 5 Does residence have a garbage grinder? ❑ Yes ®' No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: present Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq:ft., etc.):, Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 67 Fembrook Lane Property Address Brian DePierre Owner Owner's Name information is ry Centerville MA 02632 February 2 2013 required for , every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: owner, pumped in 2011 Was system pumped as part of the inspection? ❑ Yes ® No Y If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil'absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5. Official , Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 Fernbrook Lane Property Address Brian DePierre Owner Owner's Name information is ry Centerville MA 02632 February 2 2013 required for , every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1984, TOB website Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: ❑cast iron ®40 PVC ❑ other(explain): >30 Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): joints in good shape, venting through house adequate, no evidence of leakage Septic Tank(locate on site plan): Depth below grade: 1 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: 1500 gallon Sludge depth: 4" t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 Fernbrook Lane Property Address Brian DePierre Owner Owner's Name information is ry Centerville MA 02632 Februa 2 2013 required for , every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness 211 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? sludge judge, tape measure Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): pumping not necessary at this time but tank should be pumped every two to three years, tees in good condition, tank seems structurally sound, liquid level appropriate, no evidence of leakage 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 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 67 Fernbrook Lane Property Address Brian DePierre Owner Owner's Name information is Centerville MA 02632 February 2 2013 required for , every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Fernbrook Lane Property Address Brian DePierre Owner Owner's Name information is Centerville MA 02632 February 2 2013 required for , every page. Citylrown State - Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 01. 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.): dbox seems level, evidence of minor solids carryover, no evidence of leakage Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes 0 No Alarms in working order: r ❑ Yes 0 No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 e Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 Fernbrook Lane Property Address Brian DePierre Owner Owner's Name information is Centerville MA 02632 February 2 required for , 2013 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: (1)6'x6'w/3' stone El 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.): no signs of hydraulic failure or breakout, vegetation typical (ornamental shrubs andgrasses) Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Fernbrook Lane Property Address Brian DePierre Owner Owner's Name information is Centerville MA 02632 February 2 required for , 2013 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•.09l08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 Fernbrook Lane Property Address J` Owner Owner's Name information is Centerville MA 02632 1 required for 'E �,8�0�$�Ly � 'Z�J 3 every page. City/Town State Zip Code Date of Inspecti n D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within.100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately CD Yo L7-- \.J I 46 y SOB Title 5 Official inspectionfome Subsurrece Severe Oispossi System•Page 15 of 17 C r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 67 Fernbrook Lane Property Address Brian DePierre Owner Owner's Name information is ry Centerville MA 02632 Februa 2 2013 required for , every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: >12feet 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: previous inspections note no groundwater at over 12'; also, pond visible behind dwelling shows a considerable distance in elevation difference between system and groundwater. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins c O.W08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 I a r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Fernbrook Lane Property Address Brian DePierre Owner Owner's Name information is Centerville MA 02632 Februa 2, 2013 required for ry every page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage,Disposal System either drawn on page 15 or attached in separate file F t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 _ .Ib.neering Dept. (3rd floor) Map - /J Parcel (�,�� �:/ Permit# House# ti" Date Issued - Board of Health(3rd floor)(8:15 -9:30/1:00-4:30 �YI �1�V r Y 9ao oTw:1n Conservation Office (4th floor)(8:30-9:30/1:00-2:00) J'J) IINi5TALLED IN COMPLIANCE- Planning Dept. (1st floor/School Admin. Bldg.) WIT E 5 ` ENVIRON ODE AND Definitive Plan Approved by Planning Board 19 TOW e IONS TOWN OF BARNSTABLE Building Permit Application Project Street Address 69 F Ql'i/JI-L 1'`'�, L Village ,C �l/�>7� G /1� Owner Address h9 N'JZ11/yl,(�"1-� L a^-,r,7— Telephone 9 9 5 9 3 Permit Request °u "A P -First Floor ,n square feet Second Floor square feet Construction Type Were I-rocLn-a- Estimated Project Cost $ /?f�(� Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family Ip� Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House ❑Yes Q No On Old King's Highway ❑Yes pWo- Basement Type: ❑Full ❑Crawlkl4alkout ❑Other Basement Finished Area(sq.ft.) 300 ryy 1�t Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing -5 New ® Half: Existing New 0 No. of Bedrooms: Existing New Total Room Count(not including baths): Existing New First Floor Room Count Heat Type and Fuel: Gas ❑Oil ❑Electric ❑Other Central Air ❑Yes ❑No Fireplaces: Existing New 0 Existing wood/coal stove Yes ❑No Garage: ❑De ached(size) Other Detached Structures: ❑Pool(size) Attached(size) ❑Barn(size) -0 None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Aut onzation ❑ Appeal# Recorded❑ Commercial ❑Yes No If yes, site plan review# Current Use Proposed Used u Builder Information Name Z6VC,� Telephone Number 71 — Address //�,,Z M�41 License# a� r Home Improvement Contractor# /0v� Q j Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO arbM4 � SIGNATURE DATE 10—41 _If BUILDING PERMIT DENIED FOR THE FO LOWING REASON(S) L7 EDWAR / L.gwG� 61ty V.� 26100 h Af A G/STEA a� / 1 1^A I �Z6+✓. mop o f Gar�`L/ 15V �// /rig ks„ dr TLAA I I TN Z 3 tz�x ty� 6v rb /N ibNas ov : 3� ��� �,• 1 i t �T -Visi' 6`!1 Doi I I Vb LoTLZ of y 4 / /VnTe-- 4 Z,'1/,'9 77 a/VZ 13,4),5C'-D D ti il;, LOCATION . C e-W7Z-,eV14t4- /;44ss. SCALE . ./"_,0 DATE PLAN REFERENCE .BE.7--vG LoT' 'y Z 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . r I CERTIFY THAT THE ... ....... .. ...... / SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS SHOWN HEREON AND THAT IT CONFORMS TO THE SETBACK REQUIREMENTS OF THE TOWN OF WHEN CONSTRUCTED. DATE : . . . . . . . . . . . . . n Gnlcr[ncn i nun rein c"r-vnn ` ' Y �:�vlsrv�d3 Jo nlIV :Ld7a H�lb3H Commonwealth of Massachusetts 966t fi add Executive Office of Environmental Affairs Department of 02AI333H Environmental Protection Wllllam F.Weld Governor Trudy Coxe secretary,EOFJ1 David B.Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL S15TEM INSPECTION FORM PART A CERTIFICATION Property Address: �� t=�rr►Mp t�J1L (,!SL(:�wTc'r";\�� Address of Owner: Date of Inspection: It(p (If different) Name of Inspector;�Z1tQve-:-- Company Name, Address and Telephone Number: CERTIFICATION STATEMENT 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: Zasses _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Sig nALu ` Date: --2's1�i-QL( The System,Inspector shall.submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has 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 senc w me system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: -Check A, B, C,.or D: A) SYSTEM PASSES: - I have not found any information which indicates that the system violates any of the failure criteria as defined in M1310 CMR 15.303. Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the{replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis.of determination in all instances. If"not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration,or.tank failure is imminent. The system will pass inspection if the.existing septic,tank is replaced.with a conforming'septic tank as :..approved by the Board of Health. (revised 8115195) One Wlnter Street w Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-S500 �h1 Printed on Recyded.Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:'&,,-7 r--Carp;,(pircx)k owner: .Date of Inspection: BJ SYSTEM CONDITIONALLY PASSES (continued) , Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the ". Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled'or 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 A 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. ;SYSTEM WILL PASS UNLESS BOARD OF.HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or,privy is within 50 feet of a surface water Cesspool ouprivy 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 APPROPRIATE) DETERMINES THAT., THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE'' ENVIRON 1iENT: _ the SVSlem haS a teptic tanK anu soli absorption system anj 6 withiii feel io is SuliaCe -vva,ci S;jPP--l*'or tributary to a surface water supply. •y='. The system hay a septic tank and soil absorption,system and is within a Zone I of a public water supply well. The system has.a septic tank and soil absorption'system and is within 50 feet of a private water supply well. , _ The systen, has a septic tank and soil absorption system and is less than 100 feet but 50 feet-or more from a private water supply well, unless a well water analysis for coliform.bacteria and volatile organic compounds indicates that the well is !it free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less.than 5 PPM DJ SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303 The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. (revised 6/15/95) 2 � n - ' , .a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: (,a7 I"-c-v- tofc,xj(C (ti•.• C e n'r *Owner: G q a:7'vlyJCOL Date of Inspectio DJ SYSTEM FAILS (continued): Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool 1q Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. )� Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. a 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. Ariy 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 colitorm bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: } The design flow of system is 10,000 gpd of 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: 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! The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR'5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 6/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Addre s:, (a 7 Owner: (3 ti.T R; Date of.Inspection: Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. one of the,system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. t::�`As built plans have been obtained and examined. Note if they are not available with N/A. _:f The facility or dwelling was inspected for signs of sewage back-up. :f-The system does not receive non-sanitary or industrial waste flow -­rhe site was inspected for signs of breakout: 'O/AII system components, excluding the Soil Absorption System, have been located on the site. _k-fhe 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. VThe size and location of the Soil Absorption System on the site has been determined based on existing information or' t approximated by non intrusive methods.(// _ he facili;'') c.::.;r ;3 . ' 0ccopa•^.i5, If d'f' '^^. from ,ne•'o� were provided with information on the proper maintenance of Sub- Surface Disposal System. ' .stiff"' (revised`8/15/95). 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: (0 7 Owner: �e. EGcw�,c�rc Y��Q ` Date of Inspection: -'r FLOW CONDITIONS RESIDENTIAL: Design flow: 2D gallons Number of bedrooms: Number of current residents: ;-4 Garbage grinder (yes or,no): Laundry connected to system yes or no): Seasonal use (yes or no): / J� Water meter readings, if available: / Last date of occupancy:���- $ �-I �.,COMMERCIAUINDUSTRIAL: Type of establishment: Designflow: gallons/day Grease trap present: (yes or no) Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Watermeter readings,-if available: Last date of occupancy:' OTHER: (Describe) Last date of occupancy GENERAL INFORMATION r's' :x; PUMPING RECORDS and source of information: System pumped as pan of inspection: (yes or no)_ If yes, volume pumped: gallons Reason for pumping: Lso,TYPE OF STEM 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) Other(explain) r, APPROXIMATE AGE of all components, date installed (if known) and source of information: " Sewage odors detected when arriving at the site: (yes or no)' (revised 8/25/95) S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 67 F-c,-tj6r V--L j-t:: C ee•t i Owner: Date of Inspection: SEPTIC TANK: Y (locate on site plan) Depth below grade: Material of construction: t ncrete_metal _FRP—other(explain) 4*4 .Dimensions: 'Sludge depth: V4 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: /3 u Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depthrof liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) SVI.- tofrE1,.z.. ;DwrC, GREASE TRAP: ' ` (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP—other(explain) Dimensions: Scum thickness:. Distance from top of scum to top of outlet tee or baffle: Distance from tiotto.r w .r1,m 1, hntinm ot ovule! tee or bat)IP' 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 8J:S/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM INFORMATION (continued) Property Address: o7 Owner: �-—�1�c.12� c.Lc�T��v cQ Date of Inspection: TIGHT OR HOLDING TANK:/4 (locate on site plan) Depth below grade: Material of construction: _concrete_metal _FRP—other(explain) " Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: 11' ; ; -4 (locate on site plan; Depth of liquid level above outlet invert: p'(2vvVC_ -: Comments: r mote 4 level ano drstribut$uh EquBi, evidence of solid: ca:r�o�er, evidence of leakage into or out of box, etc.) .FPUMP CHAMBER: ;} llocate,on site plan) Pumps in^working:order:(yes or no) c P x,;Comments: -(note condition of pump chamber, condition of pumps and appurtenances, etc.) 7(revised 8/15/95) qK:. r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: (P-7 t Cv&M v-6-tj _ Ce A;i Owner: Date of Inspectio:t / SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: ; leaching pits, number: leaching chambers, number:_ ' -leaching galleries, number: , leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note'condition of soil, signs of hydraulic failure, level of ponding, condition of.vegetation,etc.) r;kv .w CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to inlet..invert: Depth of solids layer. y Depth of scum layer: Dimensions of cesspool: N ` 4s , Materials of construction: Indication of grounds+titer: inflow (cesspool must be pumped as part of inspection) >,:r .... Comments: (note condition of soil, signs of hydraulic failure, level-of ponding, condition of vegetation, etc.) ` PRIVY: (locate"bn site plan) �h4. 144 .Materials of construction: Dimensions: A,,Depth of solids: Comments: (note condition of,soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) B Irevised 8/15/95) ` x I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:,�p,7 �N�(JfbD(zL � GTc,-o- (aC Owner. i/C� ft��c.Tc`Yvca Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' tar a 1. k �a ' y, :DEPTH TO GROUNDWATER f-jo Depth to groundwater:_ L�feet Imo' 'method of determination or approximation: `t S 0yjc,f¢ h4= (n CA (revised 8/15/95) 9 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION.(continued) Property Address: 7 ,rNbfbdlc`�r G .�Tc��� Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' ti i s DEPTH TO GROUNDWATER ,Depth to groundwater: i�N feet ` `method of determination or approximation: — c96, v,� `t S Ov�v(rim 16-Y CQ. e_ t4 a r to rw A Cl- s�wrec T� I (revised 8/15/95) 9 I { I