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HomeMy WebLinkAbout0060 GUILDFORD ROAD - Health 60 Guildford Road Centerville P . A = 172 059 0 No. 4210 1/3 ORA Pendaflex' 100 .:1 7 9 1 i .) `� .� 9 i R ^ .Y ,�'V C'f ,� , Q���� �Q :� �,� ��° .� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 60 Guildford Rd. Property Address Barbara Lilly Owner Owner's Name information is Centerville Ma. 02632 2/01/2008 required for 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. Important: A. General Information When filling out forms on the O computer,use 1. Inspector: only the tab key to move your Robert Paolini 1 0 �j I cursor-do not use the return Name of Inspector o Tj r key. Capewide Enterprises LLC — =' zr- Company Name Gt, r� P.O.Box 763 '4 Company Addressr'i Centerville Ma. 026�32 _ City/Town State Zip lode (508)428-4028 S14454 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 ti 2/01/2008 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. 60 Guildford Rd.•12/07 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 60 Guildford Rd. Property Address Barbara Lilly Owner Owner's Name information is Centerville Ma. 02632 2/01/2008 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is - structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed 60 Guildford Rd.-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 60 Guildford Rd. Property Address Barbara Lilly Owner Owner's Name information is Centerville Ma. 02632 2/01/2008 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ` B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: _ C) Further Evaluation is Required by the Board of Health: ❑. Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if 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. 60 Guildford Rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 60 Guildford Rd. Property Address Barbara Lilly - Owner Owner's Name information is Centerville Ma. 02632 2/01/2008 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow El ® 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. 60 Guildford Rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 60 Guildford Rd. Property Address Barbara Lilly Owner Owner's Name information is Centerville Ma. 02632 2/01/2008 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a.Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. - - - --E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 60 Guildford Rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 60 Guildford Rd. Property Address Barbara Lill Owner Owner's Name information is Centerville Ma. 02632 2/01/2008 required for State Zip Code Date of Inspection every page. City/Town 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)] 60 Guildford Rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 60 Guildford Rd. Property Address Barbara Lilly Owner Owner's Name information is required for Centerville Ma. 02632 2/01/2008 every page. City/Town State Zip Code Date of Inspection D. System Information 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 1 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): 2006:49,0002007:23,000 Sump pump? ❑ Yes ® No 2/01/2008 Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 60 Guildford Rd.-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 60 Guildford Rd. Property Address Barbara Lill Owner Owner's Name information is Centerville Ma. 02632 2/01/2008 required for State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) General Information Pumping Records: Source of information: Capewide Enterprises LLC Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000gallons How was quantity,pumped determined? measured maintenance 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) El maintenance technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: New leaching pit installed in 1992 Were sewage odors detected when arriving at the site? ® Yes ❑ No 60 Guildford Rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts F Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 60 Guildford Rd. Property Address Barbara Lill Owner Owner's Name information is Centerville Ma. 02632 2/01/2008 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): 10'+ Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight No evidence of leakage System vented through the house vents. Septic Tank(locate on site plan): 18" 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 ----------=-------------------------------------------------------------- 8'6"x4'10"x57' Dimensions: 0 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle na 0 Scum thickness Distance from top of scum to top of outlet tee or baffle na Distance from bottom of scum to bottom of outlet tee or baffle na tank pumped at inspection. How were dimensions determined? 60 Guildford Rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form Not for Voluntary Assessments ,c4 60 Guildford Rd. Property Address Barbara Lill Owner Owner's Name information is Centerville Ma. 02632 2/01/2008 required for State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump septic tank every 2 years.lnlet and outlet tees are in place.Noevidence of Ieakage.Tank appears structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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): 60 Guildford Rd.-12/07 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Q w 60 Guildford Rd. Property Address Barbara Lill Owner Owner's Name information is Centerville Ma. 02632 2/01/2008 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) 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 Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert D-Box not present Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 60 Guildford Rd.•12107 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 60 Guildford Rd. Property Address Barbara Lill Owner Owner's Name information is Centerville Ma. 02632 2/01/2008 required for every page. City/Town State Zip Code Date of Inspection D. System Information.(cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type. ® leaching pits number: 2-1000 gallon ❑ 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.): Sandy dry soil.No signs of hydraulic failure.Old leaching pit water to invert was 28" .New leaching pit was dry with stain lines 46"to invert. 60 Guildford Rd.-12107 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ,M 60 Guildford Rd. Property Address Barbara Lilly Owner Owner's Name information is Centerville Ma. 02632 2/01/2008 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 60 Guildford Rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Map ra�,c i vi Town of Barnstable Geographic Information System \.Parcel Viewer Custom Map Abutters Map Size ® Zoom Out J J g J j fIn l 3;.,._ }J7 7 r� w. - r1 CIO i i r� ; 1 i' i 0 20 Feet Set Scale 1" = 20 I Aerial Photos f n—irinhh,>onr-'3,007 Tn... of P.,—fohlo RA all rinhtc r...— http://www.town.bamstable.ma.us/arcims/appgeoapp/map.aspx?propertyH)=172059&mapp... 2/1/2008 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 60 Guildford Rd. Property Address Barbara Lilly Owner Owner's Name information is Centerville Ma. 02632 2/01/2008 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of pits 40' 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: As-Built Card ❑ Checked with local excavators, installers (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:Gaherty&Miller model 12/16/94 ground water elevations.USED:USGS Observation Well Data.USED:Technical Bulletin 92-000-01 plate#2annual ranges of ground water elevations. 60 Guildford Rd.-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 Town of Barnstable OF THE Tp� Regulatory Services NSTABLE Thomas F. Geiler,Director MASS.9. ��� Public Health .Division tED pMy A Thomas McKean,Director 200 Main Street,Hyannis, MA 02601 Office: 508-862-4 644 _ Fax: 508-790-6304 .This septic system inspection report was completed by a private.inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. 9 In addition,by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the"Disposal Work-Construction Permit". I� If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS F DEPARTMENT OF ENVIRONMENTAL PROTECTION MAP _.. EPARCEL , LOT TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM. PART A CERTIFICATION Property Address: - r�/' Owner's Name: / e c d% Oa63„L Owner's Address: 6 O u,' o NOV eM Date of Inspection• /o i G - /� HEAL T i;G_ f Name of Inspector:(please print) %Y i /Gl r Company Name: i x 119 EC/� Mailing Address: Pp box Telephone Number: O� CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that below is true,accurate and complete as of the time of the' the information reported iOa Tbe inspection was training and experience in the proper function and maintenance of on si t e sewag 15340 performed based on my disposal approved system inspector pursuant to Section . of Title 5(310 CMR e al systems.I am a DEP a this ppo s The system; Conditionally Passes - Needs Further Evaluation by the Local Fail Approving Authority Inspector's Signature: Date: /� �bL6! The system inspector shall submiFacopyy of this inspection rDreport to the Approving Authority(Board of Health or EP)within 30 days of completing this inspection.If the system,is a shared system or has a design flow of 10,000 gPd or grtater,the inspector and the system owner shall submit the report to the DER The original should be sent to the system owner and copies sent tothe buyer,if appropriate regional office of the authority. applicable,and the approving Notes and Comments ""This report only describes conditions at the time of is time.This inspection does not address how the system will inspection inof use that conditions of u . the futarbe derrthe same or tions at se Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Go e� v� Sol 4.La, Owner. 1c o Date of Inspection: /O ,Q e O Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D - Syste assess - I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CUR 15.304 exist Any failure criteria not evaluated are indicated below. Comments: B• S yem Conditionally Passes: or more system components as described'in the"Conditional Pass"section need to be iced or repaired The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If not explain. determined"please The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is stnuctarally unsound,exhibits substantial infiltration or exfiltration or tank failure is nnmmcut.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 Cert dcate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or approval of Board of Health):Obstructed pipe(s)or due a broken,settled or uneven distribution box. System will pass inspection if(with broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipes)are replaced obstruction is removed ND explain: t , Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: (O d 6; cVveJ D� f/C a y� Owner: , Date of Inspection: to j'7 VJFFu(,her Evaluation is Required by the Board of Health: onditions 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 1&303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water — Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form 3. Other: • Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A - - -- - - - - CERTIFIC-ATION`contin ( ued) Property Address: ce %"Az-;1�J2 Owner: ail o, Date of Inspection; 02e 0 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the followingfor all _rnspecdons: Yes Ng/ _ __y_�E�ackup 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 l/ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or V"-- pool iquid depth in cesspool is less than 6"below invert or available volume is less than% ' pumping day now more than 4 times in the last of times pumped Y NOT due to clogged or obstructed pipe(s).Number - 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 1 tri butary to a surface V17water supply. portion of a A�pb cesspool or privy is within a Zone 1 of a public portion of a cesspool or Pub c well. Y privy is within 50 feet of a private water supply well. — Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or leas than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system f�.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 gpd- Of 10,000 gpd to 15,000 ou must indicate either`yes"or"no"to each of the following: following criteria apply to large systems in addition to the criteria above) y no the system is within 400 feet of a surface drinldng water supply _ _ the system is within 200 feet of a tributary to a surface drinking water supply the system is looted in a nitrogen sensitive area(Interim Wellhead Ptotection.Area—1WPA)or a mapped Zone H of a public water supply well If you a answered"yes"to any question in Section E the system is considered a significant threat,or answered "Yes" ' 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. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B - - // � CHECKLIST. Property Addn/ss: 0 6:64, 6 >"oe-j A' Owner. PG r o y ✓�' e (�63�' Date of Inspection: !0 d L 9 Check if the following have been done You.must indicate`"yes."or"no"as to each of the foIIowing� Yes o _ . — — Pympmg 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 C—// vohmaes of water been introduced to the system recently or as part of this.mspec don Were as built puns of the system obtained and exam ed?9 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,owbc in g 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 1icgi4 depth of sludge and depth of scam Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes z}o/� (—/ 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)P 10 CUR 15.302(3)(b)l f Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C (D /�- _ -_- -- Y�STEM INFORMATIO1rF _.__----.---------------------- Property Address- 0 6r/:u:ld e ✓d Owner, f Date of Inspection: o FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example:110 gpd x#of bedrooms): Number of current residents: Does residence have.a garbage Binder(yes or no): -S Is laundry on a separate sewage system(y�,or no _ [if yes separate inspection required) - LMnXkyy system inspected(ye39E no): Seasonal use:(yes or no): Nv Water meter readings,if 7,*k(last 2 years usage(gpd)): Sump pump(yes or no): Last date of occupancy: w -f-vt COMMERCIALMMUSTRIAL Vv \\ Type of establishment: Design flow(based on 310 CUR 15.203): 2 pd Basis of design flow(seatstpersomesgft etc.): Grease trap present(yes or no):_ Ind ist rrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): Pumping Records GENERAL INFORMATION ��, Sours of i�ornration: u 0 Was system pumped as part of the inspection(yes or no:_,qV If yes,volume pumped:_gallons—How was quantity pumped determined? Reason for pumping nE OF SYSTEM —�tank distribution box, soil absorption system Single _Overflow cesspool —PdvY —Shared system(yes or no)(if Yes,attach previous inspection records,if any) InnovativdAltemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) —Tight tank _Attach a copy of the DEP approval —Other(descrbe): Approximate age of all components,date installed(if known and souse of' rmation: 14-leW Sf Were sewage odors detected when arriving at the site(yes or no):�/� Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM SYSTEM INFORMATION(continued) Property Address• Owner. P�(C✓��. Date of Inspection: a 3 BUILDING SEWER(locate on site plan) Depth below grade: 02/ Materials of construction_ inn _40 PVC_other(explain): nce Dista from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,eta): SEPTIC TANK: - pte o site_(10 / to plan} Depth below grade: Material of construction: ncuete metal fiberglass__polYethYlene If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) ` J Dimensionion s !> Sludge depth:Distance from top d Scum thick w : Ltr sludge%bottom of outlet tee or bale: ,�O Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to et tee baffle: �� How were dimensions determimk o(,c �f vi o�_ Comments(a®pumping recommendations,inlet and o et tee or baffle conditio structural integrity, as re}gted to outlet invert, 'dence of 1 ) 4 > tY,liquid levels 6wT I✓1 Qp On ,p y • 'p ep� GREASE TRAP:Macula on site plan) Depth below grade:_ Material of construction:_concrete metal_fiberglass—plyethylene_other', (explain): Dimensions: Scum thiclmess: Distance from top of scum to top of outlet tee or bale: Distance from bottom of scam to bottom of outlet tee or bale:. Date of last pumping Comments(on pumping recommendations,inlet and outlet tee or bale condition;structural Integrity, as related to outlet i nrA evidence of leakage,etc.): liquid levels Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C --------------.._._-...------------...___- Property Address: Owner. �C�L Odt[31, Date of Inspection: ,o o TIGHT or HOLDING TANK: %'(/(tam must be tamped at time 0f mspection)(locate on site Dian).. . Depth below grade: Material of construction: oo!=ete metal fiberglass_.polyethylene other(explain)- Dimensions: Capacity gallons Design Flow: talloiWday Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping Comments(condition of alarm and float switclies,etc.): DISTRIBUTION BOX: (if present must be opened)(loca on site plan) Depth of liquid level above outlet urvert: f16 — /�?V -X, Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or orrt�bo .r PUMP CRAM FJ:./ �Qonsiteplan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): • Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C_ --SYSTEM[ ----co- - - .. _ . INFO R N MATIOn ' Property Address: ©d-ic 32- �o u r r Owner, e l c �. Date of Inspection: 10 SOIL ABSORPTION SYSTEM(SAS): pocate on site Pam,excavation not required) e If SAS not located explain why: T� leaching pits,number (�/ • leaching chambers,number. leaching galleries,number; leaching fteenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/aitemative system TyPelname of technology: Comments(note condition of soil,signs of hydraulic failuree,Ievel of etc.): po�� condition of vegetation, CESSPOOLS: (oemvool 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: Y Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic fa>7ure,level of Ponding,condition of vegetation,etc.): PRIVY/V (/locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic WuM level of ponding,condition of vegetation,etc.): page 10 Of 11 t OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTE1C -E OIIMATIaN - Property Address: (�;O, /ej sZk Owner. f e G f-�!, Date onnspection: v o SEETCH OF SEWAGE DOPOSAL SYSTEM-. Provide a sketch of the sewage disposal system including ties to at least two pennaaent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building, f-ro V —6J7 1x ��� � A?- `t3 L P ys i � _ 3,2 e . Page 11 of 11 a OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ---- ----_.._. ... . ------ - - - -- ---- - YYTEM INFORMATION(continues— --:-- - - ----....- -- ---Prop" -- Address: (!�0 r 5p�yyr,qld Pj / •c." vr,/r, Owner. ��(C, &I Date of Inspection: OZ 6 p SITE EXAM Slope Surface water / Check cellar Shallow wens i Bstunated depth to ground water 3 PJfeet - Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on mcofd-If cheer date ofdesign plan reviewed- site(abutting popu y/observation ho1h grin 150 feet of SAS) t/ Checloed with local Bowd of Health-explain; 1"'�G Checked with Iocal excavators,installers-(attach documentation) Accessed USGS dam: 10F You mnst you established high d wa jig is / 9.2 s.,9. S1��✓ d-3,3 zo t V i 0 o ��� < t t f o U0 e \D C' `' �,-{ '` ` 1 V i ,dirk 90 5,� , 4 9• 6iro L4 ki C �� � 3l ' No..1 � �l'�. l Fes$ ............. THE COMMONWEALTH F APPRMW BOARD OF HEALTH Ts Con�r TOWN OF BARNSTABL 'F Appliration for Bhipvii al Workii C ontitrurtiu ami# oat® Application is hereby made for a Permit to Construct ( ) or Repair K) an Individual Sewage Disposal System at: .. /!---------• fJ/ 12 5. 1 `�......... ........�`f�1�J% r�/GC ......._.._....... Location-Add ss or Lot N .....------...... ��t. .... _4.........�z�-<�.!LD ,G , ------ r rr ✓ ......__ o; Owner Address W Installer Address Type of Building Size Lot,=-,-> q. feet U Dwelling—No. of Bedrooms.............. ....._____.__....__..._Ex Expansion Attic p ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixt�ur-e�-s.---•----•-•- -------•-----•••---••-•---------•-----••------•----•---••--•---------- ---------•---•-----•-------•••-•-•-•--••------._........_.... WDesign Flow...................... ..................gallons per person per day. Total daily flow----------- o..................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 ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................ LC, Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water........................ -----------------------------------•-- -•----------------------•---•.....-• •-------•--••-------.........----------....----..._......----••-••••---...... 0 Description of Soil.................6''��-------o�--P•�--'!'�.-- -<-S sSUl'-------�..' ` ----,e. x =e------•-------•••••------••--•••••----•--•-•-•-•--------•---•-•--•------------•----•--•----•----•......................................... U W x --------------------------------------------------------- ---------------------------------------------------------- ------------------------------ -- - --- -------------- --------- U Nature of Repairs or Alterations—Answer when applicable------- ------.__-------------------------- -G ........................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complianc as b en issue by t oard of health. Signed ------ -- - -----................ ----- . --------------------------.----.........----- Dt Application Approved By £%�� �' -- ---------- �`-'s/ �`` `— . ------------------------------ _ Dare Application Disapproved for the following reasons- ---------------------------------------------------- --------------------- ---------------------------------------------- ------ ................................................................ ...........................................Dare------ ----'---.....-----------............... ¢ Dare Permit No. ! ------------------ Issued .. `"..... ,L--l`=.. ..... ---- --------------- --- -- -- ............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE f ApVtiratiou for Di-qVviial Works Tonotrnrttn Purrmit Application is hereby made for a Permit to Construct ( ) or Repair OK/, ) an Individual Sewage Disposal System at: ..........,%�. �U�LD ✓zD_s ..may ........................................................... Location-Address or Lot No. /�✓/cl//l C j, •---------- �'1 1 =£y...............f 4 !L 1.�( .......................................... -- ------ Owner Addressn� 0 ,,r 1S% // f �1.����` 2 1-4' ��//L S � Instal.I.er Address t d Type of Building Size Lot 4� , 4..._.Sq. feet Dwelling—No. of Bedrooms............... ......................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria dOther fixtures -----------------------------•••---------------------------------------------------------------------••-•-----••-----...... ------ W Design Flow.................. �..._-_-_--------gallons per person per day. Total daily flow............ ��U_......_....._....gallons. Septic Tank—Liquid capacity------------gallons Length-___•__-___---- Width................ Diameter---------------- Depth................ W 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 ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ f3� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ----------------------------------------------------------•----------.....-•-------....----•-.......•..._•••...............--•----• ......•-•-••-•--•....-- D Description of Soil------------------ -------•e_—k ._ _:._ G ,Sc� ...zo.......... j.................... W ----------------------------------------------------------------------------------------------------------------------------------------------------------/-� V Nature of Repairs or Alterations—Answer when applicable.......r4 D _______-/G D�aY._ /�/-/U -----------------•--•.... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance,fi s b en issued'by the board of health. Signed:- /........... Da Application Approved By _...-•..---���----�------------ �-.. - -- A------1...'-�1-�'-.��� 7 Date Application Disapproved for the following reasons- --------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------- -----------------------------" ...-.. �5--�Date Permit No. ..... Issued ........... f'... fl.- ..--f..... Dace ../� THE COMMONWEALTH OF MASSACHUSETTS �l BOARD OF HEALTH { , TOWN OF BARNSTABLE } THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) b ,Cs' /L c,, v /;`� `C uca-id nJ y - ------------------------------------------------------------------......................... Installer at ------------------ ------------------------------------------- ...... ......................................................-..-......-4' LJ//4 s � G/�'7� 1T`E"/d I I C E ------------------------------------ --------------------------------------------------------------- has been installed in accordance with the provisions of TITLE of The State Environmental Code as scribed in ol the application for Disposal Works Construction Permit No. Y,.. " dated _ '`-- �'" ._ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO STRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. '�� DATE . .. . 1 ------------------------------------- ----- Inspector ------------��.I �-/ THE COMMONWEALTH OF MASSACHUSETTS /7 U r� r % r BOARD OF HEALTH 0�v !�� TOWN OF BARNSTABLE No.•................... FEE........................ RsVasal Workii TWnstrnrtUan Prrmit Permissionis hereby granted •. ---•-••-----•--••••••-•••••••---••••••---••-•••-•-•--------••-•.........•-••••.................•--...... to Construct ( ) or Repair (><) an Individual Sewag Disposal System atNo......................................... ..6.A........... ...............................................................S !maC'f 7T�'�tJ/L4� •-----------------•-----••.---•- Street Q /� as shown on the application for Disposal Works Construction Per. n.:t 6._ __7j_ mat d..._: ... ..... 14 Board of Health DATE.,,./.--/-/---....---.....Y-----�--- ............................ FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS L 7 TOWN OF BARNSTABLE r LOCATION (O &2011-b SEWAGE # VILLAGE SSESSOR'S MAP & LOTO-2-0,55 INSTALLER'S NAME & PHONE NO `�2—/ocaw SEPTIC TANK CAPACITY /00,6 LEACHING FACILITY:(type) zJT ) -(size)— NO. OF BEDROOMS PRIVATE WELL OR IC WATER BUILDER OR OWNER �f yyy9� DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: / d l VARIANCE GRANTED: Yes -�No- l r y�� j ' ® 1. �� J