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HomeMy WebLinkAbout0136 GREEN DUNES DRIVE - Health 136 GREEN DUNES Centerville A = 245 - 019 �I i S M E A D No.2-153LOR UPC 12534 emead.com • Made in USA r WU9EDHTWPRO =UME SFI D*SR WWWWWROC-PAKOW Commonwealth of Massachusetts aye (P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �V 136 Green Dunes #1 of 2 systems Property Address Robert Nossa&Jennifer Odell Owner Owner's Name information is required for every W. Hyannisport MA 02672 10/19/2020 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not way. Please see completeness checklist at the end of the form. y be altered in any Important:When filling out forms A. Inspector Information S 1 00l on the computer, use only the tab James Ford key to move your Name of Inspector cursor-do not Ford Septic Services, LLCServices, LLC use the return Company Name key. P.O. Box 49 � Company Address Osterville MA 02655 City/Town State Zip Code 508-862-9400 S12482 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Ne4rthertion by the Local Approving Authority 4 ❑ Fa 10/19/2020 Inspe Date The sl submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Green Dunes 1 of 2 s stems Property Address Robert Nossa&Jennifer Odell Owner Owner's Name information is required for every W. Hyannisport MA 02672 10/19/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 i. Commonwealth of Massachusetts Title 5 Official Inspection Form 1?, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 136 Green Dunes 1 of 2 systems Property Address Robert Nossa&Jennifer Odell Owner Owner's Name information is required for every W. Hyannisport MA 02672 10/19/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The'system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 f - Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 136 Green Dunes 1 of 2 systems Property Address Robert Nossa &Jennifer Odell Owner Owner's Name required for is every W. Hyannisport required for eve MA 02672 10/19/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet.of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems:: You.must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form X Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 136 Green Dunes 1 of 2 systems Property Address Robert Nossa&Jennifer.Odell Owner Owner's Name information is required for every W Hyannisport MA 02672 10/19/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd: ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 3110 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ® the system is within 400 feet of a surface drinking water supply ❑ ® the system is within 200 feet of a tributary to a surface drinking water supply ❑ ® the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Vic,., 136 Green Dunes 1 of 2 systems Property Address Robert Nossa &Jennifer Odell Owner Owner's Name information is W. Hyannisport MA 02672 10/19/2020 required for every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional:office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of.the Soil Absorption System(SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t51nsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form orm < Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Green Dunes_ 1 of 2 systems Property Address Robert Nossa &Jennifer Odell Owner Owner's Name information is required for every W. Hyannisport MA 02672 10/19/2020 page. Cltyrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: Unknown Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® -No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail: unavailable Sump pump? ❑ Yes ® No Last date of occupancy: currently Date t5insp.doc-rev.7/26/2018. Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 c Commonwealth of Massachusetts ,. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments </ 136 Green Dunes 1 of 2 systems Property Address Robert Nossa &Jennifer Odell Owner Owner's Name information is W. Hyannisport MA 02672 10/19/2020 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: unavailable Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form <�= Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Green Dunes 1 of 2 systems Property Address Robert Nossa&Jennifer Odell Owner Owner's Name information is required for every W. Hyannisport MA 02672 10/19/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: installed 6/30/1986 per as-built Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑cast iron :®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form X Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Green Dunes 1 of 2 systems Property Address Robert Nossa&Jennifer Odell Owner Owner's Name information is every W. Hyannisport required for eve MA 02672 10/19/2020 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 14"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene y El 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: 1000 Sludge depth: 2 Distance from top of sludge to bottom of outlet tee or baffle 21 Scum thickness 5 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 15 How were dimensions determined? 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.): The Tee's were present. There was no sign of leaks a The covers were 14" below 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 136 Green Dunes_ 1 of 2 systems Property Address Robert Nossa &Jennifer Odell Owner Owner's Name information is required for every W. Hyannisport MA 02672 10/19/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain): N/a Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene y ❑ other(explain): N/a Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ISubsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Green Dunes 1 of 2 systems Property Address Robert Nossa &Jennifer Odell Owner Owner's Name information is required for every W. Hyannisport MA 02672 10/19/202 0 page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): N/a *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Even 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.): The D-box was normal. The cover was at 12" I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Green Dunes 1 of 2 systems Property Address Robert Nossa&Jennifer Odell Owner Owner's Name information is required for every W. Hyannisport MA 02672 10/19/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): n/a * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1- 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Green Dunes 1 of 2 systems Property Address Robert Nossa &Jennifer Odell Owner Owner's Name information is W Hyannisport required for every MA 02672 10/19/2020 page. Cltyrrown State Zip Code Date of inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.j Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The pit was dry and clean. The scum line was 2' up from the bottom. There was no sign of failure. The cover was at 2' 12. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): n/a t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Green Dunes 1 of 2 systems Property Address Robert Nossa &Jennifer Odell Owner Owner's Name information is required for every W. Hyannisport MA 02672 10/19/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: N/a Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form F Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �v 136 Green Dunes 1 of 2 systems Property Address Robert Nossa &Jennifer Odell Owner Owner's Name information is required for every W. Hyannisport MA 02672 10/19/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately BACK 1 i a 3 y a B 1 33 P(* a 3a y3 P©o I 33ye49' t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Green Dunes 1 of 2 systems Property Address Robert Nossa &Jennifer Odell Owner Owner's Name information is required for every W. Hyannisport MA 02672 10/19/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Topo 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: see above Before filing this Inspection Report, please see Report Completeness Checklist on next page. Lmn.p.d..•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 r r ` v Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 136 Green Dunes 1 of 2 systems Property Address Robert Nossa &Jennifer Odell Owner Owner's Name information is required for every W Hyannisport MA 02672 10/19/2020 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4(Failure Criteria) and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 5_ 0 g Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Green Dunes #2 of 2 systems Property Address Robert Nossa&Jennifer Odell Owner Owner's Name information is W. H annis ort t✓l' MA 02672 10/19/2020 required for every y p �fc/ �I�� page. Cityrrown 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. Imng out forms A. Inspector Information c5!# / /�D� filling out forms }rV on the computer, use only the tab James Ford key to move your Name of Inspector cursor-do not Ford Septic Services, LLC use the return Company Name key. P.O. Box 49 ,ae Company Address Osterville MA 02655 AA Cityrrown State Zip Code � 508-862-9400 S 12482 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4 ❑ Fails 10/19/2020 InsperSignature Date Thetor shall submit a copy of this inspection report to the Approving Authority (Board of Hwithin 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 c Commonwealth of Massachusetts �n Title 5 Official Inspection Form I, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Green Dunes #2 of 2 systems Property Address Robert Nossa &Jennifer Odell Owner Owner's Name information is required for every yannp W. Hyannis port MA 02672 10/19/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 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: 2) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N FIND (Explain below): t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form /< Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Green Dunes #2 of 2 systems Property Address Robert Nossa&Jennifer Odell Owner Owner's Name information is required for every yannP W. Hyannis port MA 02672 10/19/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form <� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 136 Green Dunes #2 of 2 systems V Property Address Robert Nossa &Jennifer Odell Owner Owner's Name information is required for every W. Hyannisport MA 02672 10/19/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ' ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c V!% 136 Green Dunes #2 of 2 systems Property Address Robert Nossa&Jennifer Odell Owner Owner's Name information is required for every yann p W. Hyannis port MA 02672 10/19/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section CA. Yes No ❑ ® the system is within 400 feet of a surface drinking water supply ❑ ® the system is within 200 feet of a tributary to a surface drinking water supply ❑ ® the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V!% 136 Green Dunes #2 of 2 systems Property Address Robert Nossa&Jennifer Odell Owner Owner's Name information is required for every yannp W. Hyannis port MA 02672 10/19/2020 page. CityTTown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 r c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Green Dunes #2 of 2 systems Property Address Robert Nossa&Jennifer Odell Owner Owner's Name information is required for every yannp W. H is ort MA 02672 10/19/2020 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: Unknown Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: unavailable Sump pump? ❑ Yes ® No Last date of occupancy: currently Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V. 136 Green Dunes #2 of 2 systems Property Address Robert Nossa &Jennifer Odell Owner Owner's Name information is required for every W. Hyannisport MA 02672 10/19/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow.(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: unavailable Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts �6 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c !% 136 Green Dunes #2 of 2 systems Property Address Robert Nossa &Jennifer Odell Owner Owner's Name information is required for every y p W. H annis ort MA 02672 10/19/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: installed 11/23/1989 per as-built Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V!% 136 Green Dunes #2 of 2 systems Property Address Robert Nossa&Jennifer Odell Owner Owner's Name information is required for every y p W. H annis ort MA 02672 10/19/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 3"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: 1000 Sludge depth: 2 Distance from top of sludge to bottom of outlet tee or baffle 21 Scum thickness 1 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 15 How were dimensions determined? 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.): The Tee's were present. There was no sign of Ieakage.The covers were 3" below t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 136 Green Dunes #2 of 2 systems Property Address Robert Nossa&Jennifer Odell Owner Owner's Name information is required for every y p W. H annis ort MA 02672 10/19/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): N/a Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): N/a Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V!% 136 Green Dunes #2 of 2 systems Property Address Robert Nossa&Jennifer Odell Owner Owner's Name information is required for every y p W. H annis ort MA 02672 10/19/2020 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): N/a *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Even 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.): The D-box was normal. The cover was at 16" t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection on Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Green Dunes #2 of 2 systems Property Address Robert Nossa &Jennifer Odell Owner Owner's Name information is required for every p W. Hyannis port MA 02672 10/19/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): n/a * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1- 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: t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ..........c V!% 136 Green Dunes #2 of 2 systems Property Address Robert Nossa &Jennifer Odell Owner Owner's Name information is required for every yannp W. Hyannis port MA 02672 10/19/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The pit was dry and clean. The scum line was 1' up from the bottom. There was no sign of failure. The cover was at 28" 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): n/a l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form iIa Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 136 Green Dunes #2 of 2 systems Property Address Robert Nossa&Jennifer Odell Owner Owner's Name information is required for every yannp W. Hyannis port MA 02672 10/19/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: N/a Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 136 Green Dunes #2 of 2 systems Property Address Robert Nossa&Jennifer Odell Owner Owner's Name information is required for every yannp W. H is ort MA 02672 10/19/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate-where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately Ca � 1 0 01 0 Q I as ay a a,6 ao 3 36� G Y 5g aq t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 136 Green Dunes #2 of 2 systems u y Property Address Robert Nossa &Jennifer Odell Owner Owner's Name information is required for every y p W. H annis ort MA 02672 10/19/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 2e +/- fe et 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: Topo 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: see above Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V � 136 Green Dunes #2 of 2 systems Property Address Robert Nossa&Jennifer Odell Owner Owner's Name information is required for every yannp W. Hyannis port MA 02672 10/19/2020 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank— Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 U /8951�' i 515052'57"W ���175.07' X N x ' x 25. _ 40' o PROPOSED N POOL POOL RATED N FENCE AND GATE X 1D N LEACHING PIT S SEPTIC TANK (FROM B.O.H. DATA uw Ln N�l5TOCr\ADEfNC. f0 m �' STOCKADE IF NC. p N cp N PATIO z /No. 136 30.0_ 1 STY. WD. FR. Os 1 37.9'_ l r i ni 1 1 75.00' N 17°1 5'53"E w w w EDGE OF PAVEMENT GREEN DUNES DRIVE I HEREBY CERTIFY THAT, TO THE BEST OF MY KNOWLEDGE,. AND IN MY PROFESSIONAL OPINION, THE LOCATION OF THE PROPOSED SWIMMING POOL, AS SHOWN HEREON, CONFORMS WITH THE HORIZONTAL SETBACK REQUIREMENTS OF THE ZONING BY-LAW OF THE TOWN OF BARNSTABLE r f , r Commonwealth of Massachusetts m Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 136 Green Dunes Property Address Pauline Chamberlain Trust _ Owner Owner's Name information is Centervile MA 02632 May 6, 2014 required for Y 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. Importanhenfillin A. General Information When filling out forms on the M computer,use 1. Inspector: -1/- only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector Q use the return key. _,: �� -`s• Company Name i rea PO Box 1487 Company Address Marstons Mills MA 02648 ienan City/Town State Zip Code 508-776-4186 SI 12855 at r 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 May 6, 2014 Job# 14-34 In ector's ignatur 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 unr'gr 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. 07 D Iq t5ins•3/13 Title 5 Official Inspecti F j:Subsurface Sewage Disposal System•Page 1 of 17 1 i Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 136 Green Dunes Property Address Pauline Chamberlain Trust Owner Owner's Name information is Centervile MA 02632 May 6, 2014 required for y 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: Property has two systems, in similar condition and both in working order. 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 :fetal 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 ' r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 136 Green Dunes Property Address Pauline Chamberlain Trust Owner Owner's Name information is Centervile MA 02632 May 6, 2014 required for y every page. Cityrrown 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 ❑ ^'D (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 ❑ D (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 ill 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 t5ins•3113 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 3 of 17 j I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 136 Green Dunes Property Address Pauline Chamberlain Trust Owner Owner's Name information is Centervile MA 02632 May 6, 2014 required for y every page. Cityrrown 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 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 less than _day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 136 Green Dunes Property Address Pauline Chamberlain Trust Owner Owner's Name information is Centervile MA 02632 May 6, 2014 required for y every page. CitylTown 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. ❑ Z 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 ❑ 0 the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Intof,rim 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 136 Green Dunes Property Address Pauline Chamberlain Trust Owner Owner's Name information is Centervile MA 02632 May 6, 2014 required for y every page. City/Town State Zip Code Cat 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. ® ❑ 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 3 3 (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 136 Green Dunes Property Address Pauline Chamberlain Trust Owner Owner's Name information is Centerville MA 02632 i'. a 6, 2014 required for y every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 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 Water meter readings, if available (last 2 years usage (gpd)): Detail Sump pump? ❑ Yes ® No Last date of occupancy: Currentlyoccupied. 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-3/13 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 136 Green Dunes Property Address Pauline Chamberlain Trust Owner Owner's Name information is Centervile MA 02632 May 6, 2014 required for y every page. CityrFown 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: None 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): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 136 Green Dunes Property Address Pauline Chamberlain Trust Owner Owner's Name information is Centervile MA 02632 May 6, 2014 required for y every 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: 1989 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1 feet Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): 8" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8.5' long x 5.2'wide - 1000 gal X2 Sludge depth: 2 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts ADM. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 136 Green Dunes Property Address Pauline Chamberlain Trust Owner Owner's Name information is Centervile MA 02632 May 6, 2014 required for y 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 28 Scum thickness 2 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? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Liquid level was found at outlet invert in both tanks and all baffles were intact and clear. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments kM 136 Green Dunes Property Address Pauline Chamberlain Trust Owner Owner's Name information is Centervile MA 02632 May 6, 2014 required for y 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•3/13 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form.- Not for Voluntary Assessments 136 Green Dunes Property Address Pauline Chamberlain Trust Owner Owner's Name information is Centervile MA 02632 May 6, 2014 required for y every page. Cityrrown 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 0 il 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.): No solids or high stains present in either box, liquid level was at bottom of cutlet pipes Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 15ins•3/13 Title 5 Official Inspection Form:Subsurf�•a Sewage Disposal System•Page 12 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 136 Green Dunes Property Address Pauline Chamberlain Trust Owner Owner's Name information is Centeryile MA 02632 May 6, 2014 required for y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: Two 6x6 pits. ❑ 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.): Pits showed no evidence of surcharge. Stone and soils surrounding pits were probed with no signs of saturation found. 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-3/13 Title 5 Official Inspection Form,Subsurface Sewage Disposal System•Page 13 of 17 i M1 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 136 Green Dunes Property Address Pauline Chamberlain Trust Owner Owner's Name information is Centervile MA 02632 May 6, 2014 required for Y every page. City/Town 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 pondinp,. condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 136 Green Dunes M Property Address Pauline Chamberlain Trust Owner Owner's Name information is Centervile MA 02632 May 6, 2014 required for y every page. City/Town State Zip Code Date of Inspection 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 1 J II 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 I � Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 136 Green Dunes Property Address Pauline Chamberlain Trust Owner Owner's Name information is Centerville MA 02632 May 6, 2014 required for y every page. CitylTown 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: 15+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ® Accessed USGS database -explain: USGS topo map. You must describe how you established the high ground water elevation: Topo map shows property above el. 20. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 136 Green Dunes Property Address Pauline Chamberlain Trust Owner Owner's Name information is required for Centervile MA 02632 May 6, 2014 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 Syster ,$) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 17 of 17 { Back Yard 43 3 50 3 3 J F J F f i F i f F r 14 ♦ \ \ ♦ ♦ \ ♦ ♦ t \ f f ! ! f f f / f / f ♦ ♦ \ \ t 4 4 \ t o t 21 1 t t \ t t t t t t t ♦ ♦ t \ t t ♦ \ 4 ♦ t \ \ ♦ t \ t ♦ \ \ ♦ \ t \ \ t \ 4 ♦ ♦ \ \ ♦ t t ♦ \ ♦ t t __ f f F l f r J / r f J / J f ♦ t \ ♦ t 4 \ vt�/+y�4(/'4�j'4 \ t \ \ ♦ t \ \ t t \ \ ♦ t t \ t \ t ♦ ♦ t \ ♦ ♦ \f\/R!i�l�\J�tiM T t 4Jtrk/\ftf\ft \F t ftf J i Jtf♦ftftJtftltJtJt 3 \ \ t t \ t \ t t't ♦ t 4 t ♦ t \ t ♦ ♦ t ♦ \ t ♦ t t ♦ \ ♦ ♦ t 4 ♦ t \ 4 t \ t t ♦ t t v. \ 4 t \ \ t 4 ♦ t \ t t t \ t t ♦ \ \ t t \ 'v t t t ♦ ♦ \ \ ♦ \ \ \ ♦ t \ \ ♦ t \ ♦ \ t \ t t \ t 'v t \ t t ♦ t \ t .t \ 4 t t t t t t t t 4 \ \ t v. \ ♦ ♦ t \ ♦ ♦ 'v 'v 'v \ \ t t 2 4 LJ t \ ♦ t \ 4 ♦ ♦ ♦ t \ 4 t't ♦ t \ ♦ ♦ \ 4 ♦ t \ ♦ t \ 4 \ ♦ t 4r t \ v 4 \ \ t \ 'v 1 4 \ \ t t \ ♦ \ \ \ t \ \ t ♦ \ t v. t l 4 ♦ t \ t ♦ \ - � • r f F F F r F J r / f r f r J i f J f J t TOWN UI" BARNSTABLE LOCA TIO?N WAGE # . 52 VILLAGE ASSESSOR'S MAP 6i LOT 'Z INSTALLER'S NAME St PHOrjE NO, SEPTIC TANK CAPACITY LEACHING FACILITY:(type) -(Size) / z�a NO. OF BEDROOMS_ _P.RIVATE WELL.OR PUBLIC WATER BUILDER OR OWNER DATE PERLiIT ISSUED; j DATE COLIPLIANCE ISSUED: VARIANCE GRANTED; Yes J i I 46 /1 e AsBuilt Page 1.of 1 TOWN OF BARNSSTABLE LOCATION i 7� . �cln+t/� SHWAGE # VILLAGE�'i�cyitayy,�^ ASSESSOR'S MAP 6i LOT'1 -Q I INSTALLER'S NAME & PHONE NO. c/ SEPTIC TANK CAPACITY 4c>e7 LEACHI14G FACILITY:(type) ;fliT (size) edoo, NO. OF BEDROOMS -PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER �[sX� c( t,Q,,. DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes__ _No ✓ ti 4 a- http://issgl2/intranet/propdata/prebuilt.aspx?mappar=245019&seq=1 8/28/2015 I � , � s sus r�r/) No...1 _ ff Fps.- ....��....0 0 THE COMMONWEALTH OF MASSACHUSETTS �¢- BOARD OF HEALTH ..... ....................OF__............Barn.stabl-e Appliratiou for Bispla al Workii Towitrurtiuu P.rrutit _ Application is hereby made for a Permit to Construct ( ) or Repair (X)o an Individual Sewage Disposal System at: ........-•---...----...I11d.Qll...F...Ch mhar.1a-in................ ......•--•-----.....---........... Location-Address or Lot No. -------••-- 1`3...........................................................Green Ds We t Y�fl a nn i s p-r-----------------------------Owner Address aJ,P.Macomber Installer Address Type of Building Size Lot.............................Sq. feet U Dwelling XXNo. of Bedrooms_.......3...............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) P4 Other fixtures -----------------------------•-. . W Design Flow.................:..........................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity------------gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area-______----_-------sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed bY.......................................................................... Date........................................ ,a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water----_----__________--_-- Li, Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ a -------------•-----------------------•------•------------------.....--•--•---------••-------------------------------•-..._..-----•........................... ODescription of Soil................................................................................Band............................................................................ x U --------------------------------------------------------------------------------------------------------------------------------------------------------•----•---------------------------------------••- W -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- UNature of Repairs or Alterations—Answer when applicable..............1=10D 0-__gallon.... ank....__..._.__..._..._.......... ...........-..........................................................................................................1_-_1 Q Qf)---gallon---leach...P 1-t............•.... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with r7T l'lv--. LE the provisions of i1 l 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has betissueby e b and of h th. Signe . -- . . ---- 11 8 ® Date...Application Approved BY - ..... . . .. ...... Date Application Disapproved for the following reason -•---•-----=•-•-•-•----•------•-----...•••-••--•-----------••---•-----•----••--••-•----------.•---- �j Date OIL ............. Issued �� No....�.. ::� Fes$...{...2 it l ll^ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH App iration for Disposal Works Tonstratrtion rrrntit Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal System at: Location-Address or Lot No. 175 Gr r�zI Dunes We t .. ann..s.�or..••------._...••--•--•-••---....••--•..............•--......---••--- Owner Address a Installer Address UType of Building Size Lot............................Sq. feet .., Dwelling _ xNo. of Bedrooms.._.•....._^...............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ---------------------------------•--------------•-----•-•••-......•-•••-.--•------------------•-•-••--•••-•••••-••••---•---•-••......••--•------•... w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. fx Septic Tank—Liquid capacity............gallons Length----_-_------- Width................ Diameter---------------- Depth................ xDisposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date.-----------------------------------.... �-4 a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_.______________--_-___. Li, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-._________--__--... a •---•••-•••---•-•-----•----•----•-•--•--•-•--•--•--•-•---•-•-•-••••---••--••.........-•-•-----•-----......................................................... ODescription of Soil.................................................................................S.�n{l••----------••--•••••-•-•--•••-••••-••---•--•-•-•---••............------•--- x w UNature of Repairs or Alterations—Answer when applicable._--__-___--_1- -0.0 0 -----------------------------------••--------------------------------------•---------................--•-•---••--..... . I.... ; ., i... _ : ' f. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of i'TILE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. i :..Stgned f..... - /ff i , J 1 < '� 1 J ... r/ �� Date 7 .r Application Approved By---• ---�f ---�. . =- �= -•--•-•---------------- --------------- Date Application Disapproved for the following reason ��................r-•---•---•---..._...__......_.._.-___............•------••---•--•--... ............ -•-------------------•----------------•--------•--------...--•------------------•----------....-----•----••----•-••--••------•-••-•-•-•••---••-•-••---------------------- ---------------------------- Date Permit No...... -- ----------------- Issued_.....8 ............. 1 J y --='--- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Tots..... ...................O F..................................................................................... C�rrtif irate of Tontplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (X�K In staller ller 1 36 ;r�?t� Dult� z �, f� u has been installed in accordance with the provisions of T I,TZE , 5 of Th State Sanitary Code s descr•be(1 he f application for Disposal Works Construction Permit No..___ �.__-./J............. dated------- _ ._ _ _ r._ . �r THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS RUE® AS A GU RAN E THAT THE ;s SYSTEM WILL FUNCTION SATISFACTORY. � DATE............................f_1.. . ' 7...................... Inspector................... ...?\�.................................................. �.. ,,. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �' Te rr OF.. Barl?stable 20.00 NO...! '. ...__ FEE........................ Disposal Works T-1ontrt ion` rrmit Permission is hereby granted J.P.MaCniTber ------------------•------•-------------------•--•------------•--•-------.. ................................................ to Construct ( ) or Repair .(XXTan Individual Sem;a&e Disposal System f i.36 Green Dunes W at No.. --•--•--•-•----••••-••-----••-•-----•---•.............•-•-........•--.......--•-•--•••--•---•---- ...........est Hvanni5afjrr r' •_......--- - --•-•---••-•--•---••-- ------ . Street-' (� .i� as shown on the application for Disposal Works Construction Permit-No ._�?._.._�.� Date ------ _ � �:-fir. -•.� r Board of Health t DATE f f./ --------------•-- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS S E W A E PERMIT NO- LO CATION v , VILLAGE N SL P S ME A D D R S S�) \I C e BUILDER OR OWNER 1n F l DATE PERMIT ISSUED —� MPLIANCE ISSUED DAT E C O c i P � �2 z f4 No......g: ....... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ------..�dIN :... .� W,0r/..--......OF.... o_ ............ Appliratiun for Mopaoal Workii Tondrurtiun 11amit Application is hereby made for a Permit _C tr ct ( ) or Repair (�an Individual Sewage Disposal i Syst at: -- ._ ..446 . �. . ...� .... .......... .............•-- ... - �� ess or Lot No. - . ----------------------------.................. Own r Address ... �.......... ---------•-••• •-••••-----•••-••---•.................•--•- a Installer Address Type of Building Size Lot............................Sq. feet U Dwelling X. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building No, of persons____________________________ Showers — Cafeteria a' Other fixtures _________________________________ _ - W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 04 W Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) `-� Percolation Test Results Performed bY------------------------------•-•--••••-••--•----•--•••••••-••----••••••-• Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ---------- ••••----••••-••--••-••••--••••• .............••••----------•-•-•--....._.....-•••••-•-...----••-•-••-•-••-••-•....._.._----_••••. :::;]; Description of.Soil......... ..................................................... ---------=------------..._.....---------------•••••-••••-•••- U •-••-•.._..-•--••--•---••••----••••••••-•---•---•••-••-•••••---•---•--••-•••--••-•••••---•-•••••-•---•._._...-----•-••••...-•-•••••-••••-•--•---•--•---••••••••-••-••-•-•-•••••----••--•••--••--•...•-•- W -•-••••••--•----------------•---••-----•--------•--••---•-----------•---••-••--••---••----••••••---•-----•--••-•-------------------- UNature of Repairs or Alterations—Answer when applicable._./ .-.1 / ! Agreement: Ad The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of:ITLE 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issued by the b d. lth. Signed..... •-•- ----- Date Application Approved BY .._.,.............. Z Date Application Disapproved for the following reasons________________ ____•-_____•______-____-_______________-_______________________•___._.___..._______...._._._.. ............................. ....... _--------------- ---------- '------------- •--------------------- •----------- •---------------------------- Dau----•--------- • G-7 Permit ----•---• ------------ ----•---------- Issued_....................................................... Date No.-.............-•••••. Fxs......... _._...._. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............ ...:........................OF...... ............ .....: ........................................ App iratiun for Disposal Works Tonstrurtion rrrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ,-)an Individual Sewage Disposal System at: ....:...........— ............................................. -- .......... .:.._....••-----•----....-•---......---__....______.._...__._._.___._...... Location-Address / / or Lot No. r., r Owner • Address W .. � Installer Address Type of Building , Size Lot............................S feet U Dwelling-No. of Bedrooms.......................:....................Expansion Attic ( ) Garbage Grinder ( ) ~ Other—T e of Building No. of persons............................ Showers — Cafeteria Other fixtures ---------------------------------------------- W. Design Flow........................:...................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter.....--......... Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area...................sq. ft. 3 Seepage Pit No..................... Diameter......._.._...___.__ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by............. ............................................................ Date........................................ a Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ G4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ---•--------•-•-•- •----....••-•-••••-•..............•-...........•---• •.........._......-•----.... ..........--••-•••••--........_......•---- 0 Description of Soil.......................................................................................................................................------....-:.................---• V ............. W -•-----------------------------------------------------------•----•-------.....--•----•----.......-----....-•-------------------------•--.......--•---•---•---.....................----•-•----•----.... V Nature of Repairs or Alterations—Answer when applicable............................................................................................... ----•-------------------•------••-----•---------------................-----------••--------•---------•--•--------------------•--•----------------.....................................•••-------.-•• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T IT 1E 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed......................... •••••-•-•---•. .......:............. ............Dat.e............. Date Application Approved By..........................................................U (`2'*) -1?6 Date Application Disapproved for the following reasons:...._.... - ------------ ...... .._. -••-•-•--•••--•-•--•...................•-•--•---...........•-----...............--------.......------............------..........-----•---•-••----•-•---------•------.....•-----•-••-••••----•-••----•-- Date PermitNo...................................................-... Issued.......................................................... Date THE COMMONWEALTH OF MASSACHUSETTS - BOARD OF HEALTH ai . ................. ��.........OF.......... % ............. �'.� .......................... (Irrtif iratr of Toutplittnrt THIS IS TO CY ? IFY, hat the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by............................ a( E4...... -----------•----------............ . --•----••--•------.........-------••-----••-----............-•---••-----....-•-- .—. Installer 18 at...................................................................................................................................................................................................- has been installed in accordance with the provisions of TITLE of he State Sanitary C de a desc ' in the application for Disposal Works Construction Permit 1�'0........ .?4:2.2:� .. dated_.... THE ISSUANCE OF THIS CERTIFICATE SHALL .NOT BE CONSTRUED AS A G ANT E THAT THE SYSTEM WILL FU CT ION SATISFACTORY. �— DATE......................-• T ............................ Inspector........ •--•-••---•-------•-----..............----......____............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH grp• 2 ........................................OF.................... No... .� v�-�.f i r� �d� ��......................... Fay.... .. Disposal orkp Tons#riulion Errant Permission is hereby granted r fupaNS�.,wage.. /�.._._..•--•...--•..............................•-••-•..................to Co uct�1( or Re r ( ✓an Ind.ivi Disposal System atNo ... ... . r.r�..... ........................................................ Street as shown on the application for Disposal Works Construction Permit No................... Date ............ ...... oard of He FORM 1255 A. M- ULKIN, INC., BOSTON TOWN OF' BARNSTABLE LcC-'Af'10N SEWAGE # � 7 VILLAGE ASSESSOR'S MAP LOT S-6 i INSTALLER'S NAME PHONE NO. iY SEPTIC TANK CAPACITY LEACHING FAC.ILITY:(type) ,&i, (size) /Oao, NO. OF BEDROOMS PRIVATE WELL OR PIIBLIC'WATER BUILDER OR OWNER DATE PERMIT [SSUED: It- DATE COMPLIANCE ISSUED: 7:> - VARIANCE GRANTED: Yes No �� h'� � ` �A ,,mac`/�0' ��i t� �� � / ��i .,�, d LOCATION S E W A E PERMIT NO. VILLAGEro raT A + q INSt�LLE5S ME i ADDRkSS I U I L D E R OR OWNER DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED �O l y e t