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HomeMy WebLinkAbout0072 GLENEAGLE DRIVE - Health iL.G LENEAGLE DRIVE, CENTERVILLE A= 191 160 J�RECYCIfpC s UPC 12543 SUM $°°ncoN�� HASTINGS,MN oFTHE ram, Town of Barnstable ti�P� ti� * Regulatory Services y�MAss.. Thomas F.Geiler,Director �67g•A'EoY" Public Health Division Thomas McKean,Director 367 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 DATE: Z10 O0 Zj!!t 0 7 S� RE: ? z4. ©� The Barnstable Health Division has reviewed the Title 5 septic inspection form for the above referenced property. The following comments listed below are deficiencies according to 310 CMR 15.300 and the Town of Barnstable Health regulations. Please re- inspect the system, if necessary, complete a new report form or revise the pages pertinent to the deficiencies listed and resubmit the report to this office within fourteen(14) days: IJH3L 677 o Le/zl ,2., ho-/z —�4 d l d P-A5—e J d y tom, O s t�✓a_,o�Pi�_ f! — r ►' _ sepdef.doc .�. f7 TOWN.OF BARNSTABLE LC3i°AT10N _I� Gl r A � .fir SEWAGE # IYM LAGS CQ r tr�►�`� ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO. OF BEDROOMS 3 BUILDER OR OWNER �JO� + PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of llaching facility) 1 Feet Furnished by • v Al - as ` Ack A r1a- P- ap, O O AS' t-la- a f33- ya 3 TOWN OF BARNSTABLE toCATiON SEWAGE # VILLAGE 'C ASSESSOR'S MAP & LOT*,�L INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY D LEACHING FACILrIY: (type) Pl7- (size) Q NO.OF BEDROOMS BUILDER OR OWNERl�I�{ ERA41TDATE: 1/ l P COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If.any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 1 � 1 V r f 7 _ . � y 1 1 6Z � , ,�w . . . - - -1 TOWN OF BARNSTABLE LOCATION' �y�Yf� //� �i� SEWAGE # VILLAGE (e 0h/`/� ASSESSOR'S MAP Sz LOT INSTALLER'S NAME & PHONE NO. . SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (sue) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNE ze±�110(3 DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No �� ���� x �� ., � � s r Qi ��L '� � _ '�® i COMMONWEALTH OF MASSACHUSETi'S EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ✓ TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 72 Glen Eagle Drive Centerville, MA 02632 Owner's Name: Bob&Kim Jones Owner's Address: Same RECEIVED Date of Inspection: July 24, 2001 J U L 3 12001 Name of Inspector:(Please Print) James M. Ford TOWN OF BARNSTABLE Company Name: James M. Ford HEALTH DEPT. Mailing Address: P.O. Box 49 Map: 191 - Osterville,MA 02655-0049 Parcel: 160 Telephone Number: (508)862-9400 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 Cond' 'onally Passes N F rther Evaluation by the Local Approving Authority Fail Inspector's Signature: Date: July 29, 2001 The system inspector shall sub a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 s Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 72 Glen Eagle Drive Centerville, MA Owner: Bob&Kim Jones Date of Inspection: July 24, 2001 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. 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 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. 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- 2 I� Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 72 Glen Eagle Drive - - Centerville, MA Owner: Bob&Kim Jones Date of Inspection: July 24, 2001 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 2. System will fail unless the Board of Health(and Public Water Supplier,if auy)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 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: 3 Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A .CERTIFICATION (continued) Property Address: 72 Glen Eagle Drive Centerville, AM Owner: Bob&Kim Jones Date of Inspection: July 24, 2001 D. System Failure Criteria applicable to all systems: You must indicate either`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 less than 'h day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. _ ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool'or privy.is within a Zone 1 of a public 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 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.] 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 determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve 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 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 72 Glen Eagle Drive Centerville, M4 Owner: Bob&Kim Jones Date of Inspection: July 24, 2001 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? i ✓ 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: 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)]. 5 i Page 6 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYS,TEIVI,INFORMATION Property Address: 72 Glen Eagle Drive f Centerville, MA Owner: Bob&Kim Jones Date of Inspection: July 24, 2001 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 (per owner-rooms not inspected) DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 4 Does residence have a garbage grinder(yes or no): Yes Is lalmdry on a separate sewage system(yes or no): No [if yes,separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): 1999- 73,000 gals.;2060-69,000 gals. Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203) pd .. . _.. 'Basis of design flow(seats/persons/sgft,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: Never pumped-per owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--Hove was quantity pumped determined? Reason for pumping: The owner was having the system pumped after the inspection TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current-operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval 'Other(describe) _..Approximate age.of all components,.date.installed(if known)and.source of information: Approximately 1975 Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM'INFORMATION (continued) Property Address: 72 Glen Eagle Drive Centerville, MA Owner: Bob&Kim Jones Date of Inspection: July 24, 2001 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction,line: _ , Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 30" Material of construction: ✓ concrete _metal _fiberglass _polyethylene_ _other(explain) If tank is metal list age: Is age.confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 gal. Sludge depth: S" Distance from top of sludge to bottom of outlet tee or baffle: 27" _ Scum thickness: 15" Distance from top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle: 2" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): The tees were present. The liquid level was even with the outlet invert. There were no signs of leakage. The owner was having the system pumped after the inspection. GREASE TRAP: None (locate on site plan) 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: - F Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,'liquid levels as related to outlet invert,evidence of leakage,etc.): 7 r Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM,INSPECTION FORM PART C ,1;.•t SYSTEM`INFORMATION (continued) Property Address: 72 Glen Eagle Drive Centerville, MA Owner: Bob&Kim Jones Date of Inspection: July 24, 2001 TIGHT or HOLDING TANK: None (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 alarm and float switches,etc.): N BOX:' None if, resent must- opened) locate on site plan) 1` , .DISTRIB'UTIO .(._p _ _.r. )_(__.... . . r _ ) - - 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: None (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.): 8 Page 9 of i l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM`INFORMATION (continued) Property Address: 72 Glen Eagle Drive Centerville, AM Owner: Bob&Kim Jones Date of Inspection: July 24, 2001 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 6'x 6'(1000 gal.) 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.): The pit had 4'6"of water on the bottom.-The scum'line was at the same level. There were no signs of failure. The bottom to ,grade was approximately 10'. CESSPOOLS: None (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: None (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.): 9 i Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 72 Glen Eagle Drive ; Centerville, MA Y , Owner: Bob&Kim Jones Date of Inspection: July 24, 2001 Map: 191 Parcel: 160 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. Aa- a B,- i O O 3 10 i Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ' SYSTEM INFORMATION (continued) Property Address: 72 Glen Eagle Drive Centerville, MA Owner: Bob&Kim Jones Date of Inspection: July 24, 2001 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate (check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: ' The bottom of the pit to grade was approximately 10'. Using the Barnstable topographic map and-the Cape Cod Commission water contours map, the maps were showing approximately 25'+/-to groundwater at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection andlor this report. 11 r .o� < \ CO`INIONVIALTH OF NjkSSACHt•SETTS ExECL•TIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF E1VIRONNIENTAL PROTECTION �d ONE WINTER STREET. BOSTO-N. MA 02106 61?-:S.•S:(G t " WE V.lLL1A*'F.V�1:LD - Covcaic• - A' O Sa`s', ARGEO PAUL CELLI•CC] _ iD B S t_ t}�= Lt.Govcrnor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO -N h,FpjrgB� Co ki sion- PART A _ z CERTIFICATION es 1�•2I �5�, 1� �, s of Own e 1Z h��11S Property Address; � Addr � ' o I Date of Inspection: 7jl 11, ��p -� '/' 6 '3�-'(If different) i Name of Inspector: N.e > 'o am a DEP ap roved system inspector or pursuant to Section 15.340 of Title 3 010 CMR 13.00 ) Company Name:fzl(-- &i4-,•e Eoi 6-1 r-i N 0" Mailing Address: 2 n /3 opt r-379 4.c H r7-o Telephone Number: rSC2r 2 44-42— /4L CERTIFICATION STATEMENT I cerjf1 that I have pe-sonally irspec:ed the sewage d!sposal system at this address and that the intormation reported be ow is true. accurate and comolete a-. o=the time of inspec.o-. The inspection %as pe^crmer base-- on my training and experience in the proper funcicn anc maintenance o;on-s•te sewage disposa: :.•stems. The s•sterr.: Passes _ Concit.o-�aii% Passe! _ %%eec: Furthe- E.-a!uano- Cy t Local Approving Autnonry _ Fa.•s rr. Inspector's Signatur K N, 1K Date: v T:,e S�ste^ Insrecto• sha" submit a cope of this inspec,on reper, to'the Aporoving Authorin.. within them- (30i days of completing this inspect ion. It the wstern is a shared s\•stem o- ha; a ces,g-% flc\,. of 10.000 gx or greater, the inspe=cr and the systeT owner s'btl submit the repo^ is the aporopriate reeloral c;ice of the De;.arment of Envirenmenta' From=ior.. The crig-nal should be sent to the sysierr. a-ne and copes to the buver; ii applicable. and the aporoving authority INSPEC:iIO%% SUMMARY: Check A, B, C, Or D Al SYSTEM PASSES. I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 C-MR 15.303. Any failure criteria not evaluated are indicatec below. C0MMENT5: BJ SYSTEM CONDITIONALLY PASSES: One or more system components as described in the 'Conditional Pass- section need to be replaced or repaired. The systern, ueor, completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no. or not determined (Y. N. or NDi. 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 lanachedi indicating that the tank was installed within twenty (10) years prior to the date of the inspection: or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic cnk w approved by the Board of Health. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR-tit PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: 81 SYSTEM CONDITIONALLY PASSES Icont,n,,,!,tj. Sewage backup or out or high static water level observed in the distribution box is due to broken or obstructed pipetsl or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Healthl. Describe observations: brokers 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!sl..The system will pass tnsoection if(with approval of the Board of Health): broken pipetsl are replace:` obstruction. is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which reouire funhe•evaluation by the Board of Health in order to determine if the iystem is failing to protec: the public health. safe-.-and the environment. - 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETER,ti11NE5 THAT THE SYSTEM 15 NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT. _ Cessvooi or pn.1 is within 50 ieet of a surface water Cesspoo! or pri"- is within 50 ieet o:a bordering vegetated wetland or a salt marsh. 21 SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM 15 FUNCTIO—INGAN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND.SAFc�' AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS*j and the SAS is within 100 fee, to a surface water supply or tributan• to a surface water supoly. _ The system has a septic tank and soil absorption systern and the SAS is within a Zone I of a public water supoty well. _ The syste-n 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 thar. 100 feet but SO feet or more from a private water supply well, unless a we!I water analysis for coliform bacteria and volatile organic compounds indicates tha the we!I is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than S ppm. Method used to determine distance (approximation not valid). 3) _ OTHER (revised 01!25/7'l Page 2 of 10 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Propert% Address: Owner. Date of Inspection: DI SYSTEM FAILS: You must indicate either `Yes" or "►ro* w to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessan• to correct the failure. 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 overloaded or clogged SAS or cesspool. Sta:ic !iou,C level in the distrib,ition bo> above outlet invert due to an overloaded or clogged SAS or cesspool. Liauid depth in cesspool is less than 6"below invert or available volume is less than 1/2 da.•flov. Required pumping more than 4 times in the last year NOT due to clogged or obstructea pipes . Number o;times pumped _. Any portion of theSoil Aosorption System, cesspool or pri%,,)• is below the high groundw•ate• eievatior: An% por;:on of a cesspool or privy is within 100 feet of a surface water supply or tributan to a surface water supply. Any portion of a cesspoo' or privy is within a Zone I of a public well. An,6 pc-;io-• of a cesspool or prig• is within 50 feet of a private water supply well Any por,or. Of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supple well with no acceotable Ovate, qualm\ analysis. If the well has been analyzed to be acceptable. attach cop.- of well water analysis for coliform bacteria volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: You must indicate either -Yes" or "No" as to each of the following. The fo!iow:ng criteria app',. to !arge systems in addition to the criteria above: The system serves a facilin with a design flow of 10,000 gpd or greater (Large System; and the system is a significant threat to public hea!th and safety and the environment because one or more of the following conditions exist. Yes No . the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone II of a public water supply well) 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 CA1R 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revaaed 04/25/91) page 3 of 10 a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PARTS CHECKLIST Propertq ��ddcess:1Z Owner: ,t,Gijvq/t, Date of Inspection:A Check if the following have been done: You must indicate either "Yes'or 'No' as to each of the following: No Pumping information was provided by the owner, occupant, or Board of Health. u _ None of the system components have been pumped for at least two weeks and the system has been receiving normal -+-'� flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As bull; plans have been ootamed and examined. Note if they are not available with N,A. _ The iac:li-.% or dwelling. was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. _ The site %%as inspected for signs of breakout. All systerr. co nponents, excludme the Sool .Aosorpuon System, have been located on the site. The septic tank rranhoie� Nere uncovered. opened. and the interior of the septic tank was inspected for condition of baffies or tees. materta' o`construction. dimensions, deptn of liquid, depth of sludge, depth of scum. _The size and location of the Soil Absorption System on the site has been determined based on. The iac,l.t,. o,..ne- .ano occupants. ti diiteren: trom ov.•neri were provided with miormation on the proper maintenance of Sub•Sunace Disposal Svsterr.. SExisting iniormation. Ex Plan at B.O.H. _ Determined in the meld +if an-, of the failure Criteria related to Pan C is at issue, approximation of distance is unaccez):abie (15.302;31:bl! (revised 04/25/511 Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: �(��too� Owner: }/L(Q(/� Date of Ihspection: "r�,v_ • FLOW CONDITIONS RESIDENTIAL: Design flo%�) a p.d1bedroom for S.A S Number of becrooms Q3 Number o'current residents 01 Garbage S,;;der (yes or no::_ Laundry cor—ected to system Ives or no!. Seasonal use Ives or no!:A__) AA Water meter readings. if available (last two f2: year usage tgpol: v o Sump Pump lves or noa_ Lac dare o**occupanc\ COMMERC;4L'INDLISTRIAL• Type of establishment Design fio%% ea!ionsida\ Grease trap present Ives or no_ Indus-ma! %%aste holding Tani: oresen; Ives or no_ ':on-sanna-, iAaste discnargec to the T!;,e 5 sys;em. ;yes or no_ eater meter readings if availabie Las:jdxe o: o cL.;a­ic. OTHER: .De:cube Last care of occuoanc. GENERAL INFORMATION PUMPING RECORDS and source of informat'or System pumped as par, or inspec;uon. Ives or noj[�!6 If ves, volume pumped gallons Reason for pumping TYP OF SYSTEM Septic tank 'so,l absorption system Single cesspool Overflow cesspool Privy Shared system (yes or not (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site. (yes or not (revised 04111111, Page 5 of 10 • SUBSURFACE SE�%AGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:z�rqUV,3P(4A— Owner: . Date of Inspection:',' BUILDING SEWER: (Locate on site plan) r Depth below grade. Material of construction. _cast iron _40 PVC _other (explain) Distance from private water supply well or suction li-t Diameter —.— Comments: fcondiuon of joints, venting, evidence of leakage, etc.) SEPTIC TANK:Akc (locate on site Depth below. gradeAL material of construction: Aconcre:e _me:a _Fioerglass _Polvethvlene _othertexplam :it , trance (les-%o If tank is me-,a;. Its: see Is age conf"rmec o Ce-t ca-e of Com p � g Dimensions Sludge depth Dtsiance from top o: 'i�dee to bono-t of ou:ie: tee o• ba�;e Scum thickness-_� &(� Distance from top o: scum to top o'outle: tee or bale I� Distance iron bosom of scum to bo-o-t o,ouile: t c• bars How dimensions were determined lik Comments trecommendation for pumping, rondillor O ini nd outlet tees or baffles. depth o liqui level to rel lion t outlet inv stru ural integrity, evidence of leaka e. el:c.t - t w GREASE TRAP: (locate on site plan; 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: (recommendation for pumping. condition of islet and outlet tees or baffles. depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) lrov.vod 04/75:9:) Pag• 6 of 10 TIT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propert% Address: ON ner: / Date of Inspection: TIGHT OR HOLDING TANK: lank must be pumped prior to. or at time, of inspectioni (locate on site plan, Depth below grade. Material of construction. _concrete _metal _Fiberglass _Polyethylene _other(explain Dimensions. Capacity- gallons Design floM galions•aa. Alarm level Alarm in %%orking orde•_ Yes. _ No Date of previous pur+ping Comments (condition of inlet tee. condaior o' a!a•m and float switches. etc.) DISTRIBUT1O% BOV— (locate on site pia- De.-ih o' licuid level a00,e oune: line^ Comments tnote leve! and d:su:but+on is eoua- evidence of sol s carryover, evidence of leakage into or out of boa, etc.) PUMP CHAMBER: (locate on site plan_ Pumps in working order: (Yes or No/dtion Alarms in working order (Yes or NoComments. (note condition of pump chamber, cumps and appurtenances, etc.) (reviled 04/25/97) Page I of 10 j .. J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C C SYSTEM INFORMATION (continued) Property Addr-ss: Z Owner: ( Date of Inspection: I SOIL ABSORPTION SYSTEM (SAS): RS (locate on site.plan, if possible, exca"XZ� not required. but may be approximated by non-intrusive methodso If not determined to be present, explain: Type: leaching pits. number. x leaching chambers, number:_ leaching galleries, number. leaching trenches. number,tength: leaching fields, number, d,•nensjons overflow cesspool, numbe- Alternative system name of Tecnnoiog,. Comments mote condit on f soii, s r of hvd�aul ilure. Ieve' f ndin condit Not ve lion c.t � SICAKI CESSPOOLS: (locate or site play. Number and conitgura:.on Depth-top of liquid to inlet Inver, Depth of solids Jaye- Depth of scum layer Dimensions of cesspoo: Materials of constructior Indication of groundwate- inflow (cesspool must De pumpeC as par, of inspection} 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.) (revived 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM I%FORMATION (continued Propert% Address:w�,"1"" Owner: \`w Q1 Qv 7 Date of In,pection:�I� G(� SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all well$ within 100' (Locate where public water supply comes into house) 2 1 �2LAJf Zt s (rrva u'_ 04-25/57) page 9 of 10 _ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C +� SYSTEM INFORMATION (continued) Propert. ddres. [ Qt,JS�Q►RiQ , _ Own Date of Inspection: Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation o'Site (Abusing property. obser%ation hole, basement sump etc.) Determine it from local conditions Cnec'K %%ith Iota! Board o• -iea!tr Chec'. Fi:.Nt:, ntam Check pu nping records Check Iota! excavato,s installe•s l se 5':: Da-z Desci be - %cx e%.- ores no•. %o: es:ao!!<_hed the ~i&% Grouno�ater Elevation. (Must be completed off« �-� �\ ` I Page 10 of 10