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HomeMy WebLinkAbout0102 HARBOR HILLS ROAD - Health 102 Harbor Hills Road Centerville P A = 247 084 I No. 42101/3 ®RA Pau(,o� Eng 10% D © o 0 i -�e17' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r1a 102 Harbor Hill Road V Property Address Cfi DEYO Owner Owner's Name information is ✓ W required for every Centerville MA 02632 10/22/16 page. City/Town State Zip Code Date of Inspection ,p Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Trevor Kellett use the return Name of Inspector key. TK Septic Inspections VQ Company Name 38 Vacation Lane Company Address West Yarmouth MA 02673 Lay i own State Zip Code 5085795502 S113744 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 10/28/16 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. t5ins•3/13 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 A P j4d 0 I Commonwealth of Massachusetts Title 5 Official Inspection Form m Subsurface Sewage Disposal System Form-Not for Voluntary Assessments - -w , 102 Harbor Hill Road Property Address tv'f#t DEYO Owner Owner's Name information is required for every Centerville MA 02632 10/22/16 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 P Y Y p A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: El. One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes","no" or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts lull Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 102 Harbor Hill Road Property Address DEYO Owner Owner's Name information is required for every Centerville MA 02632 10/22/16 page_ City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass-inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health).- El broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 102 Harbor Hill Road Property Address DEYO Owner Owner's Name information is required for every Centerville MA 02632 10J22J16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water.Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 102 Harbor Hill Road Property Address DEYO Owner owner's Name information is required for every Centerville MA 02632 10/22/16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year MOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply El El Area system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 102 Harbor Hill Road Property Address DEYO Owner Owner's Name information is required for every Centerville MA 02632 10/22/16 page, City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® El available 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: Z ❑ 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(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 102 Harbor Hill Road Property Address DEYO Owner Owner's Name information is required for every Centerville MA 02632 10/22/16 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 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: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-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 w 102 Harbor Hill Road Property Address DEYO Owner Owner's Name information is required for every Centerville MA 02632 10/22/16 page. City/Town 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: 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 I ❑ 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 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 102 Harbor Hill Road Property Address DEYO Owner Owner's Name information is required for every Centerville MA 02632 10/22/16 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Approximate age of all components, date installed(if known)and source of information: 2000 according to permit number Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.2 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.): 1 Septic Tank(locate on site plan): Depth below grade: NA feet Material of construction: 0 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: Sludge depth: I t5ins•3/13 Title 5 Ot6dal Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 102 Harbor Hill Road Property Address DEYO Owner Owner's Name information is required for every Centerville MA 02632 10/22/16 page. City/Town 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 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 How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 Forth:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form_Not for Voluntary Assessments 102 Harbor Hill Road Property Address DEYO Owner Owner's Name information is required for every Centerville MA 02632 10/22/16 page. City/Town 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 Disposed System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 102 Harbor Hill Road IWO` Property Address DEYO Owner Owner's Name information is required for every Centerville MA 02632 10/22/16 page. City/Town 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 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* Comments(note condition of pump chamber, condition ofpumps 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: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w �l 102 Harbor Hill Road Property Address DEYO Owner Owner's Name information is required for every Centerville MA 02632 10/22/16 page. City/Town state Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ® overflow cesspool number: 1 ❑ 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.): There is one 7x6 cesspool that is down 8"the bottom is at 8 feet,the overflow is dry with a stain line 2'8"up from the bottom. Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration 2 in line Depth—top of liquid to inlet invert 4'1" Depth of solids layer 6" Depth of scum layer 1 Dimensions of cesspool 6x6 Materials of construction Drywell blocks Indication of groundwater inflow ❑ Yes ® No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ti 102 Harbor Hill Road Property Address DEYO Owner Owner's Name information is required for every Centerville MA 02632 10/22/16 C' /Town State Zip Code e. City/Town Date of Inspection page. P Pe D. System Information (coot.) Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.)- No ponding or indication of high groundwater or failure Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 102 Harbor Hill Road Property Address DEYO Owner Owner's Name information is required for every Centerville MA 02632 10/22/16 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 Back of house A B 0 0 A1)28 A2)37 B1)35 B2)22 t5ins•3/13 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 102 Harbor Hill Road Property Address DEYO Owner Owner's Name information is required for every Centerville MA 02632 10/22/16 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. 30 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: You must describe how you established the high ground water elevation: usgs shows groundwater at 30 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 102 Harbor Hill Road 19j,- Property Address DEYO Owner Owner's Name information is required for every Centerville MA 02632 10/22/16 page. cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 J r t. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 102 Harbor Hills Road Li t om$ Property Address Evelene Corrigan Owner Owner's Name information is Centerville MA 02632 July 16 2007 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:When filling out A. General Information forms on the computer,use 1. Inspector: only the tab key to move your David D. Coughanowr cursor-do not Name of Inspector use the return key. Eco-Tech Environmental Company Name VQ 43 Triangle Circle Company Address Sandwich MA 02563 ity/Town State Zip Code w r0 108 364-0894 1328 ca elephone Number License Number <n B. Certification -� I certify that I have personally inspected the sewage disposal system at this address and that the infoKmation 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 sews a a disposal systems. I am a DEP - 9 P Y 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 July 16, 2007 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 DER 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. t5-2707.doc-08106 Title 5 Official inspection Form:Subsurface Sewage Disposal System P g p y tem•Page 1 of 15 -.1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 102 Harbor Hills Road Property Address Evelene Corrigan Owner Owner's Name information is Centerville MA 02632 Jul 16, 2007 required for y every page. Cityrrown 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: ® 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: Inspector's Note==> Aseptic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. Eco-Tech recommends replacing block cesspools with a complying Title 5 septic system for safety reasons. 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 obstructedpipe(s) or due to a broken settled or uneven distribution box. System y m will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed t5-2707.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 102 Harbor Hills Road Property Address Evelene Corrigan Owner Owner's Name information is Centerville MA 02632 July 16 2007 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. L65-2111.&c-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 • Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 102 Harbor Hills Road Property Address Evelene Corrigan Owner Owner's Name information is required for Centerville MA 02632 July 16, 2007 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: x� 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 ❑ ® 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. t5-2707.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 102 Harbor Hills Road Property Address Evelene Corrigan Owner Owner's Name information is required for Centerville MA 02632 July 16 2007 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cunt.): 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- 1 0,000g pd. ❑ ® 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. t5-2707.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 �i Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' M 102 Harbor Hills Road Property Address Evelene Corrigan Owner Owner's Name information is required for Centerville MA 02632 July 16, 2007 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? SAS also inspected ® ❑ Were all system components, excluding the SAS, located on site? No Tank ❑ ❑ 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)] t5-2707.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 if Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M 102 Harbor Hills Road Property Address Evelene Corrigan Owner Owner's Name information is required for Centerville MA 02632 July 16, 2007 every page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): rVa Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a—no plan Number of current residents: 0 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 ears usage d 68 gpd 9 ( Y 9 (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: June 1, 2007Date 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): t5-2707.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 µ Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 102 Harbor Hills Road Property Address Evelene Corrigan Owner Owner's Name information is required for Centerville MA 02632 July 16 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Owner's agent 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) ❑ Tight tank.Attach a copy of the DEP approval. Other(describe): Approximate age of all components, date installed if known an source o information:pp g p ( ) d ur f Informatl n. Age unknown. Dwelling was constructed in 1966. No design plan found at Board of Health. Were sewage odors detected when arriving at the site? ❑ Yes ® No t5-2707.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 102 Harbor Hills Road Property Address Evelene Corrigan Owner Owner's Name information is required for CentervilleY MA 02632 Jul 16, 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 2feet 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.): Sewer appears structurally sound with no evidence of backup or leakage into dwelling Septic Tank(locate on site plan): 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: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? t5-2707.doc•08/06 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 { v Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 102 Harbor Hills Road Property Address Evelene Corrigan Owner Owner's Name information is required for Centerville MA 02632 July 16 2007 every page. City/Town 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.): 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): t5-2707.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 i v Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 102 Harbor Hills Road Property Address Evelene Corrigan Owner Owner's Name information is required for Centerville MA 02632 July 16, 2007 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 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 t5-2707.doc•08106 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 ,M 102 Harbor Hills Road Property Address Evelene Corrigan Owner Owner's Name information is required for Centerville MA 02632 July 16, 2007 every page. Cityrrown 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: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ® overflow cesspool number: 1 ❑ 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.): Soils above overflow cesspool were unsaturated. Overflow cesspool was dry with staining to 4 feet, and no lush vegetation was observed. Cesspool is constructed of concrete blocks. NOTE ON BLOCK CESSPOOLS—Block cesspools consist of concrete blocks arranged in a beehive formation and are held in place by gravity and soil pressure.Driving vehicles over or near block cesspools could potentially destabilize the structure and lead to collapse. no NOT nRIVF VFHI IrFS OF ANY SORT NFOR CFSSPnnI S. t5-2707.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 I + Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 102 Harbor Hills Road Property Address Evelene Corrigan Owner Owner's Name information is Centerville MA 02632 July 16, 2007 required for State Zip Code Date of Inspection every page. Cityrrown D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): 1 primary and 1 overflow Number and configuration 5 ft Depth—top of liquid to inlet invert See comments Depth of solids layer See comments Depth of scum layer 4 ft x 6 ft approximately Dimensions of cesspool Concrete block 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.): Cesspool contained about 1 foot of scum,sludge and effluent.Surrounding vegetation appeared normal.Cesspool volume was insufficient for pumping to be effective,but pumping is recommended when facility returns to full time occupation. NOTE ON BLOCK CESSPOOLS—Block cesspools consist of concrete blocks arranged in a beehive formation and are held in place by gravity and soil pressure.Driving vehicles over or near block cesspools could potentially destabilize the structure and lead to collapse.DO NOT DRIVE VEHLICES OF ANY SORT NEAR CESSPOOLS 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.): t5-2707.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �,M s 102 Harbor Hills Road Property Address Evelene Corrigan Owner Owner's Name information is required for Centerville MA 02632 July 16, 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. OVERFLOW• MARY CESS OOL OP CESSPOOL LOCATIONS OA 1 22 Ft 28 Ft 2 35 FE 37 FE A EXISTING a DWELLING # 102 W Z J W F 3 HARBOR HILLS ROAD NOT TO SCALE NOTE ON BLOCK CESSPOOLS—Block cesspools consist of concrete blocks arranged in a beehive formation and are held in place by gravity and soil pressure.Driving vehicles over or near block cesspools could potentially destabilize the structure and lead to collapse.DO NOT DRIVE VEHLICES OF ANY SORT NEAR CESSPOOLS t5-2707.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 102 Harbor Hills Road Property Address Evelene Corrigan Owner Owner's Name information is required for Centerville MA 02632 July 16, 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 20+ Estimated depth to ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: 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: Barnstable GIS Department records You must describe how you established the high ground water elevation: Town of Barnstable GIS Department records indicate that the property is over 20 feet above groundwater table. t5-2707.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 DATE: 4/.17/02 PROPERTY ADDRESS: 102 Harbor Hills Road ----------------------- Centerville,Mass. ------------------------ - 42g42------------------ On the above date, I Inspected the septic system at the abo .COVED This system consists of the following: 1 . 2-6 'X8 ' block cesspools in series. MAY 0 3 2002 TOWN OF BARNSTABLE HEALTH DEPT. Based on my Inspection, I certify the following conditions: 2. This is not a title five septic system. MAP 3. This is sewage system. PARCEL 0S4- The' sewage system is in proper working order . - at the present time.The overflow cess pool is_ ,dry _and^the 2'3 bottom is clean sand- This pool has - seen very little nseage. z �32 SIGNATURE: �' J. Name:-J.. P.- Macomber Jr ______ Company: Josei)h_P. Macomber-& Son , Inc . Address: - Box 66 Centerville, Ma . 02632-0066 -------------------- Phone:----508-775-3338 ----------------- THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY (JOSEPH P. MACOMBER & SON, INC. Tan ks-Cesspool:-Leachflelds Pumped & Installed Town Sewer Connections P.O. Box 66 Centerville, MA 02632-0066 775.3338 775-6412 i COMMONWEALTH OF M.A.SSACHUSETTS t EXECUTIVE OFFICE OF ENVIRONMENTAL, AFFAIRS DEPARTMENT OF ENVIRONMENTAL., PROTECTION TITLE S OFFICIAL, INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM FORM PART A CERTIFICATION Property Address: 102 Harbor Hills Road Centervi e ,Mass . Owner's Name: Julie Rogers Owner's Address'6 Crawford Street Nnrrhhnrn ,MaGs _ 01532 Date of Iospectlon: 4/17/02 Name of Inspector: (pplease print) Joseph P.Macomber Jr . Company Namc:J. 1' .Macomber & 6on Inc . Mailing Address:Box 66 C,anterville ass .02632 Telephone Number: SQR_775=3'A3R CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is True, accurate and complete as of the time of the inspection.The inspection was performed based on my rraining and experience in the proper function and maintenance ofon site sewage disposal systems. I am a DEP approved system Inspector pursuant to Sectlon 15.340 of Title 5(310 CMR 15.000). The system: Z,Passes Conditionally Passes _ Needs Further Evaluation by the Local Approving Authority Fail �J Inspector's Signature: Date: The system inspector shall bmit 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 authorirj,. Notes and Comments "''This report only describes conditions at the time of Inspectlon 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 differcot ' conditions of use. Title 5 Inspection Form 6/I5/12000 page I Page 2 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 102 Harbor Hills Road Centerville , Mass . Owner: Julie Rogers Date of Inspection: 4/17/0 2 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. S stem Passes: AID I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 3 10 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: The sewage system is Droner working order 'at the nre.GPnt time. B. System Conditionally Passes: _�)O_ 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. Ng,Vv—The e tic 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: e Observation of sewage backup or break out or high static water level in the istribution bo ue to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System wt pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced obstruction is removed _ distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 I , Page 3ofII OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 102 Harbor Hills Road entervi e , ass . Owner: j11] i Rog r Date of Inspection: 4/17/02 C. Further Evaluation is Required by the Board of Health: VO 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: yt' 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. Svstem 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: 10 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. ,60 The system has a septic tank and SAS and the SAS is within a Zone I of a public water supple. tO The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.,eV The system has a septic tank and SAS and the SAS is less than I OQ feet b 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 T 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. ther: This is a` sewage .system. The system consists of two oc cess,p:oo s -in serie3 . 1nerSewa e. s_ is. in proper working order at e , present time- 3 l Page 4 of 1 I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) ProperryAddress: 102 Harbor Hills Road entervi e , ass . Owner: Julie Rogers Date of lnspection:4 17 02 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes ��Das ckupof sewage into facility or system component due to overloaded or clogged SAS or cesspool charge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Altzl& Static liquid level in the ismbution box bove outlet invert due to an overloaded or clogged SAS or _ s✓ cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than h day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number /of times pumped 0 jAny 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 I of a public well. i�Any �ny portion of a cesspool or privy is within 50 feet of a private water supply well. 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 filtrate 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.] Alb (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303. therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large 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. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no r/the system is within 400 feet of a surface drinking water supply a system is within 200 feet of a tributary to a surface drinking water supply _ _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered ..yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant fhreat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 i ,Page 5 of I I c OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 102 Harbor Hills Road Centerville ,Mass . Owner: Julie Rosters Date of Inspection: 4/1 7/0 2 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes N _ ,. Pumping information was provided by the owner,occupant, or Board of Health LZ/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 N A Was the facility or dwelling inspected for signs of sewage back up I/ Was the site inspected for signs of break out? _ Were all system components,4w*luding the SAS, located on site? �1 ye, Were the eptic tank anholes uncovered,opened, and the interior of the tank inspected for the condition sludge and depth of scum? f liquid,depth of sl e of the baffles or tees,material of construction,dimensions,depth o q p g p 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: P Y Yes n V , _ Existing information.For example,a plan at the Board of Health. _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 r Page 6 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 102 Harbor Hills Road Centerville,Mass . Owner: Julie Rogers . Date of Inspection: 17 02 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Nutrnber of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: �Lt• JP,+03lI Does residence have a garbage grinder(yes or nodle Is laundry on a separate sewage system or no):7F [if yes separate inspection required) Laundry system inspected yes or no): Seasonal use: (yes no): S 2000-18�,000 gallons=98. 63 GPD Wafer meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no): V0 2001-23, 000 gallons=128. 86GPD Last date of occupancy:-mewleY+ % ! COMM ERCLAULNDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203):_ gpd Basis of design now(seats/persons/sgft,etc.): 41A Grease trap present(yes or no): Ay Indusrrial waste holding tank present(yes or no):/to Non-sanitary waste discharged to the Title 5 system(yes or no):,&! Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: TiPy�/�1�4� Was system pumped as pan of the inspection(yes or no): If yes, volume pumped: gallons-- How was quantiry pumped determined? 4* Reason for pumping: nf� TYPE OF SYSTEM i(J Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy 4�6 Shared system(yes or no)(if yes,attach previous inspection records, if any) 11 Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) 424 Tight tank Attach a copy of the DEP approval 1!�V Other(describe): 161�) Ap r/o-xJmpatre0 ase of a I c mpo/t jltts,date installed (if known)and source of information: Were sewage odors detected when arriving at the site(yes or no)/� 6 Page 7 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 102 Harbor Hills Road entervi e ,Mass . Owner:Julie Rogers Date of Inspection: 4 17 02 BUILDING SEWER(locate on site plan) A 7'� Depth below grade: Materials of construction:_✓cast von _40 PVC&2 other(explain): .r.* Distance from private water supply well or suction line: le' ' Comments(on condition of joints, venting,evidence of leakage,etc.): Joints appear tight No evidence of leakage .The system is vented through the house vents . SEPTIC TANKf4C(locate on site plan) Depth below grade:f9 _ Material of construction: V4 concrete metal t:•9 fiberglass.P/�olyethylene ,UAother(explain) .G19 If tank is metal list age:&�Ji Is age confirmed by a Certificate of Compliance(yes or no):�/A(attach a copy of certificate) Dimensions: /lam Sludge depth: ilu4 Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: y/j Distance from top of scum to top of outlet tee or baffle: _ Distance from bottom of scum to bottom of outlet tee or baffle: g24 How were dimensions determined: Ald Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Septic tank is not present/ GREASE TRAMIW(locate on site plan) Depth below grade: Material of construction:�t�concrete.,�&metal�9 fiberglassILitpolyethyleneALYother (explain): 14M Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping:._� Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Grease trap is not present 7 Y Page 8 of) I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 102 Harbor Hills Road Centerville . Mass . Owner: Julie Rogers Date of Inspection: TIGHT or HOLDING TAN}C; sjZ,-(tank must be pumped at time of inspect ion)(locate on site plan) Depth below grade: -i4 Material of construction: .e'4 concrete.0-4 metalj&j_fiberglass,y�olyethylene .G4 other(explain): aA Dimensions: .t�4 Capaciry: IV-4 gallons Design Flow: A gallons/day Alarm present(yes or no): 14 Alarm level: A14 Alarm in working order(yes or no): AM Date of last pumping:_i 14 Comments(condition of alarm and float switches,etc.): Tight or holding tanks are not present . DISTRIBUTION BO .t°e (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): Distribution box is not present . PUMP CHAMBEPAk"?(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): P q�p chamber is not present 8 Page 9 of I 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 102 Harbor Hills Road Centervil le'Mass . Owner: Julie Rogpr'S_ Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) Two block cesspools in series System is in nrnner wnrkinP nrtlar at the present time . If SAS not located explain why: Located ; see page 19 Type ,(1C� leaching pits.number: leaching chambers,number: Q leaching galleries,number: 7) leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number:—L nn innovative/alternative system Type/name of technology:,F'fYd/' Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): Loamy sand to boney fine sand No siggs, pf hydraulic fa; 1 nre or ponding Soils are dry_ V_ a4_rar; nn ; c nnrmal CESSPOOLS: / (cesspool must e pump as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: "y Depth of scum layer: Dimensions of cesspool: 6� Materials of construction: C' Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Same a abo v PRIVY(locate on site plan) Materials of construction: Dimensions: A)4 Depth of solids: dih Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.): PrivX is not present - 9 Pagc 10 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Properry Address: 102 Harbor Hills Road entervi e , ass . Owoer. Julie Rogers Date of Inspcctioo: 4/17/02 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide s sketch of the sewage disposal system including tics to at least two permanent reference landmarks or ocnchmuks. Locatc all wells within 100 No. Locate where public water supply enters the building. N t , log, r.> ► s Y d 10 Page l l of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:102 Harbor Hills Road Centerville .Mass . Owner: Julie Rogers Date of Inspection: 4/17/0 2 SITE EXAM Slope Surface water Check cellar Shallow wells 0 Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: A10 Obtained system design plans on record-If checked,date of design plan reviewed: Observed site(abutting prope bservation hole within 150 feet of SAS) A,0 checked with loca oar of Health-explain: ^t Checked with local excavators,installs ( ach documentation) t--'A-ccessed USGS database-explain: /./,. You must describe how you established the hi h ground water elevation: Used ; Gahrety & Miller Model . GroundWater elevations above sea leve . Used ; USGS . observation well data . June 1992 Used ; USG ec nica u etin. 92-000-1 Plate # 2 . Annual ranges of ground TihVP0q1 evat ions Leaching Pit Z zl 'eet 1�AI Groundwater: Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method Therefore,the vertical separation distance between the bottom Of the leaching pit and the adjusted groundwater table is feet. 11 •r.+++r.r-n�r*--'r•.r.'rmrnrnrr-n.rrmrn.r-.-..•.+.�.r:�srmn++ne+�isr�-m�n mn .^"ITT"r^+''...•,r... ']'OWN OF Barnstable WARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION ...rn-r.......r--.i�-.-.T.�r:+n•n:rT rnn•�t+tarrn•.�—a��mr�ar+nr•-�+�� er� mnn ++r.•.-•rrrr..._. . -TYPE OR PRINT CI.CARLY— PROPERTY INSPECTED STREET ADDRESS 102 Harbors Hill Road Centerville ,Mass . ASSESSORS MAP, BLOCK AND PARCEL # 247/084 OWNER' s NAME Julie Rogers PART D - CERTIFICATION NAME OF INSPECTOR Joseph P .Macomber Jr . COMPANY NAMEJ •P .Macomber & Son Inc,*' ' COMPANY ADDRESS Box 66 Centerville , Mass. 02632 Street Town or City State CIP COMPANY TELEPHONE (508 ) 775 _ 3338 FAX ( 508 ) 790 - 1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true'; accurate , and omplete as of the time of •inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems , .Check one : /Systeui PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health of the environment as defined in 310 CMR 16 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* \ The inspection which I have con UC ted has found that the system fails to Protect the public health and the environment in accordance with Title 5 , 310 CMR 16 , 303, and as specifically noted on PART C - FAILURE CRITERIA of this inspection form , Inspector Signature Dat':Z"��`. ..Z -- — - ne copy of this rt.ification must be provided to the OWNER, the BUYER (where applicable ) and the DOARD OF HEAL1'!f, * If the inspection FAILED, the owner or operator shall upgrade ' the system within one year of the dnte of the inspection, unless allowed or required otherwise as provided in 3.10 CHR 15 . 305 . partd .doc No. 2-M2 Fee S� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 0(ppfication for Oi!5pomf *pgtem Construction 30ermit Application for a Permit to Construct( )Repair(✓jpgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No. ��S Own is Name,Ad�,ress and Tel No. r r.a( ZA rA`J ��y Assessor's Map/Parcel �. /�yA/!n�-s��d r .. /C 1l;�{ /l o/'�/<C2, Installer's Name Address,and Tel.No. Designer's Name,Address and Tel.No. f C,4,0 C a A/�� -77s Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) (4 C-e 11- Awc /Yt a l�r Ge.S`rho e / Cu-t 5 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health.\ Signed V %)�ac.�.c.� Date o) O U Application Approved by Date a -ff. ngd Application Disapproved fort following reasons Permit No. ,Lgaom � `l3 `�' Date Issued TOWN OF BARNSTABLE LOCATIONL , SEWAGE # �Q VILLAGE 1.4' f� PomT ASSESSOR'S MAP LO INSTALLER'S NAME PHONE NO. A & B CANCO T/ —6264 SEPTIC TANK CAPACITY /PL ookg tt �iNt M�iN oso� - pL£,P rcdv LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR �WNE r-h A Al DATE PERMIT ISSUED: -//•o0 DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No i 0 i �►d� rl L/ S_d No.� _L Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: t' PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01ppfication for Migogar *pgtem C-on.5truction Permit Application for a Permit to Construct( )Repair(Upgrade( )Abandon( ) ❑Complete System ❑Individual Components r / Location Address or Lot No. ,f Owner's Name Ad ress and Tel.No. Pl pP r 1 Assessor's Ma /Parcel Ail 17 v•r , %i �. /ry / (v l; ' %►C �1rv /� /1 /A,UI��n IVtC( Installer's Name,Address,and Tel.No. l ,r is Designer's Name,Address and Tel.No. Type of Building: R` Dwelling No.of Bedrooms_� Lot Size sq. ft. Garbage Grinder( ) „ . Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil r Nature of Repairs or Alterations(Answer when applicable) 2r �G c-e G"O,=SE g o o Gut O c%r Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation'until a Certifi- cate of Compliance has been issued by this Board of Heal h. Signed \ l _ Date ) - /,-- O U Application Approved by Date n i Application Disapproved for th foll ing reasons Permit No._ 5�� C�- -4° Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance f THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( ) Repaired ( )-upgraded( ) Abandoned( )by t"-q/U(' 0 at //) 4/4 r L-,a —ZL//� has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. '1 R�, _�r Sk dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the sy to will,function as designed. Date Inspector 6� / kr i G� ------/�-�r -------------------------------- No.—v —=� { Fee �Q THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 'Wi5pogal *pgtem Construction permit Permission is hereby granted to Construct( )Repair( grade( )Abandon( ) System located at &) Z14.-f Z6 a— /Sl.//1 �,, �� �ii� //Ij and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. Date: Approved by 4 — l I TOWN OF BARNSTABLE ��'• LOCATION jI9;2 %i,QoR 141uJ /tD SEWAGE # l�o VILLAGES ;Y, n,e'_ _ ASSESSOR'S MAP & LO�Ay INSTALLER'S NAME & PHONE NO. A & B CANCO 775-6264 -SEPTIC TANK CAPACITY PL Oak#CC l/Nt i7,lnv Os01- - oyt•P FGajv LEACHING FACILITY:(type) (size) NO.OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No L R APR • as O � 70 TROY WILLIAMS SEPTIC INSPECTIONS RE�ivE0 nr l � Certified by MA Department of Environmental Protection to"OF (508) 385-1500 19 Hummel Drive �ii� i South Dennis, MA 02660 r G p V LX COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 TRUDY COKE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ' L CERTIFICATION Property Address: �d Nar f or /T• Name of Owner &e_K9_l cl ray c- "+ Address of Owner: Date of Inspection: I/ 9 /y 9 O Z O 3 8 Name of or:(Please PrinO i N �P�t Troy Williams �/ / M�• I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: Troy Williams ce to 1c Inspections Mating Address: 19 Hummel Drive, So. Dennis MA 02660 Telephone Number: (508) 385-1300 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience In the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspectoes Signature: � sti.a Date- The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to tlhe system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS Although system meets the minimum requirements set forth by the Massachusetts Department of Environmental Protection,certification is not to be construed as a guarantee of future working condition of system,piping or components. This inspection represents the conditions of the system on the Date of Inspection noted above. revised 9 /) /Qa _ i. 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(contirxied) Property Address: Owner: 102 Harbor Hills Road,West Hyannisport,MA Date of kispection: N Gerald Fagan INSPECTION SUMMAI�?vetk9,�99$, C, o/ D: A. SYSTEM PASSES: /1I//9 I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES:^///,9 One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination In all instances. If "not determined",explain why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction Is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed revised 9/2/98 Page 2of11 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 102 Harbor Hills Road,West Hyannisport,MA Owner: Gerald Fagen Date of Inspection; November 9, 1999 C. FURTHER EVALUATION 15 REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 11 SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WfTH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of 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 W A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic-tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER Q J 1 cc. S c c Go n.n. ft'S r �✓ ��S✓� O IC revised 9/2/98 Page 3of11 �xy v SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(contimied) 102 Harbor Hills Road,West Hyannisport,MA Property Address: Gerald Fagen Da Date November 9, 1999 Date o of Inspection;f D. SYSTEM FAILS: Iy/A You must indicate either "Yes" or"No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Y _ Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less-than 100 feet but greater than 60 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria, volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: N You must indicate either"Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system Is located in a nitrogen sensitive area(Interim Wellhead Protection Area=IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Po8 e4orit SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 102 Harbor Hills Road,West Hyannisport,MA Owner. en Gerald Fa Date of ksspection: Fag en 9, 1999 Check if the following have been done: You must indicate either "Yes' or 'No' as to each of the following: Ye; No _ Pumping information was provided by the owner,occupant,or Board of Health. � s« Qcc.>p�..�r J }� None of the system components have been pumped foret least two weeks and-the system has been•receivingnormal flow fit° rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _/ N�/a As built plans have been obtained and examined. Note if they are not available with N/A. JC _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System,have been located on the site. NIA'► The septic tank manholes.were uncovered, opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: N1/9 Existing information. For example, Plan at B.O.H. Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance Is unacceptablel / 115.302(3)(b)) y - _ The facility owner(and occupants,if different from owner)were.provided with information on the.propertnaintanance.of SubSurface Disposal Systems. revised 9/2/98 Pagrsorll v SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: O1N1er: 102 Harbor Hills Road,West Hyanrlisport,MA Date of Inspection: Gerald Fagan November 9, 1999 FLOW CONDITIONS RESIDENTIAL: Design flow: /1 0 g,p,d./bedroom. Number of bedrooms(design):3 Number of bedrooms(actual): Total DESIGN flow .33 0 Number of current residents: O Garbage grinder(yes or no):Alo \ Laundry(separate system) (yes or no): /0: If yes, separate inspection required Laundry system inspected '(yes or no) Seasonal use(yes or no): YE s Water meter readings,if available(last two year's usage(gpd): ?4,)o0 G ���r S � ) = y�ona� It—" Sump Pump(yes or no): NO Last date of occupancy: OLLµ>',p,,wl v Lc pr (� /ems } uS< A 5-,— COMMERCIAL/INDUSTRIAL: h//j9 Type of establishment: Design flow: qpd (Based on 15.203) Basis of design flow Grease trap present:(yes or no)_ Industrial Waste Holding Tank present:(yes or no)_ Non-sanitary waste discharged to the Title 5 system:(yes or no)_ Water meter readings,if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of Information: }� T NO 92w—pa; 4 ;h A a✓c.* I C,s /1 a>< par n t A&6 Jt J rc."-+;i,"...>` /�%•r+ �. Systafn pumped as Art of inspection:(yes or no),AVn If yes,volume pumped: gallons Reason for pumping: TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool ZOverflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,If any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all co onents,date installed Vf known)and source of information: (J•Yr a,-,�.� / A. vs. C,," I+- 0.�opvWW. 1dr-s o fa. Sewage odors detected when arriving at the site:(yes or no) Nv revised 9/2/98 Page 6of11 TOWN OF BARNSTABLE LOCATION Zd/t�*/—VJV ' SEWAGE # VILLAGE ASSESSOR'S MAP & 1,041�q G I INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY t— LEACHING FACILITY: (type),44W* ��4 e/ (size) NO. OF BEDROOMS BUILDER OR OWNER�G1 z PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: I Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland Le 'ng Facility(If any well ds exist within 3 f f 1 , try) Feet Furnish by G P , \\ Q,\ �' � � s o , � �� ` 1 �` I�o�, li� 1'a TOWN OF BARNSTABLE LOCATION'/0 Z SEWAGE # � f VILLAGE 1J- Nti,u w. y�®� ASSESSOR'S MAP & LOTc2 I INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY _ LEACHING FACII.ITY: (type) 0-15 Se2Ja S (size) X:S NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by� o" 5 f1 A �y t . _ w �� ,.�� S� �� -. 1 r > o ® `_ +�4 Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: 102 Harbor Hills Road,West Hyannisport,MA Date of Irupection: Gerald Fagen BUILDING SEWER: November 9, 1999 (Locate on site plan) i Depth below grade: Material of construction:Zcast iron 40 PVC Zother(explain) -- n -<-. . Distance from private we er supply well or suction line W 49 Diameter "Y"i Comments: (condition of joints,venting, evidence of leakage,etc.) �4 �JMt �rO N.1N N LSC (.p]UI WG�5 741y C.I ✓LCN4 ct JyLl //II b.[i TG��C Ch L4Y A✓ I [A ,A 7 SEPTIC TANK: Il ,q V d✓^cwY j �t " rl J i'' "4 cv++ { ✓. �.,< rt h at '>''D !',ao�- ro✓ 6 c. .tc. �..f. /✓v�c (locate on site plan) p�>j�-+�- Sv f r+��. / 5 S c tG N�. o Depth below grade:_ Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age_ Is.age confirmed by Certificate of Compliance_(Yes/No) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: .Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level In relation to outlet invert,structureFintegrity, evidence of leakage,etc.) GREASE TRAP• (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural Integrity, evidence of leakage,etc.) revised 9/2/98 Page 7ofIt v SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: 102 Harbor Hills Road,West,Hyannisport,MA Date of kupection: Gerald Fagen November 9, 1999 TIGHT OR HOLDING TANK: /✓/4(Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensions: -- --- Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order:Yes_ No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION sox N/19 (locate on site plan) Depth of liquid level above outlet invert: Comments: (note-if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box;etc.) PUMP CHAMBER: NI1 (locate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) revised 9/2/98 Psge9of11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: 102 Harbor Hills Road,West Hyannisport,MA Date of 4upection: G�era�ld„Fagpen N SOIL ABSORPTION Q&f 0KjA s)197 (locate on site plan, if possible; excavation not required,location may be approximated by non-intrusive methods) If not located,explain: Type: leaching pits,number:_ leaching chambers,number:_ leaching galleries,number:_ leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number:QH Alternative system: Name of Technology: Comments: (note condition of soil,signs of hydraulic failure,level of pondin damp soil,condition of vegetation, etc.) 0.} `L Od / Lx Jct H k 4 'LJ• *7 Q.-✓f �GHGL U�.,� � ,., ov ✓or w+c. t'� i aver /o bab/ C 12 exN� •; ft o/c c r.,r. 4 fD/o 1ror./ o/ eyeJL✓N c Jp�c._r CESSPOOLS: �t ,S �,�I¢- o.•� 1 �r"t o �i hsp� c�'.s n. (locate on site plan) Number and configuration: r7vrc IM ea 1 Depth-top of liquid to inlet invert:_ ulrSL__ Depth of solids layer: J "r Depth of scum layer: No N Dimensions of cesspool: 'I /� ;wry Materials of construction: r-e-C S o 1 6/a c k Indication of groundwater: A/oNE inflow(cesspool must be pumped as part of inspection)_ < r s000cy�cJ7juc. Comments: ( ote condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.) �,�,,,-,s �- wGrc— w is o 7�✓r.A, �y�s,.ep}aril � 1fia.lte o✓er fC/off J;n� � / i�ti/f d� To c�n.A � e% � mod- l3/oak r h -� o�h or6 (locate on site plan) 1 'r' f �� ruA �✓ r' �z} I tit r.J�cs fp'✓..J r.-:r j%,, .�.. �r. ht�,l. o � r-e.p r. Y. t77r+,c r 6/oC_I1,S i`. C.vo w✓+. o.per+-�nr�d� Materiels of construction: Depth of solids: Dimensions: Comments: (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.) revised 9/2/98 Psge9orit SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date r:Ins 102 Harbor Hills Road,West Hyannisport,MA Gerald Fagen November 9, 1999 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) I prv�` 1 po 3s , 23 ' 6uuiT/orJ ��• h �s S�poo 1 . C, s seoa 1.. revised 9/2/98 Page 10ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continiedl Property Address: Owner: 102 Harbor Hills Road,West Hyannisport,MA Date of Inspection: Gerald Fagen November 9, 1999 NRCS Report name Soil Type_ Typical depth to groundwater 3 USGS Date website visited /�I 1.-� a`/ 9• Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater IStFeet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record �Observed Site 1Abutting property,observation hole,basement sump etc.) / V Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators,installers Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) �0.hv\ r+.Jr,.t✓LO( SrS � low �0f-/'�� �. �GYtt�ptS� wws y.8 GcssroJ ( s w ✓t G ,L /v4L.c-4--c-4 /^ revised 9/2/98 Page 11 of 11