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HomeMy WebLinkAbout0021 JOHNNY CAKE ROAD - Health 21 Johnny Cake Road r Centerville P 4 A = 210 047 No. 4210 1/3 ORA Pendaflexe Ili: 10°0 Department of Public Health/.Department of Labor&Workforce Development td P NOTIFICATION OF DELEADING WORK All sections of this form must be completed in order to comply with i the notification requirements of M-G.L.C.1 11§197, t�jJ=0 454 CMR 22.00 and 105 CAVIR 460.000,as most recently amended .-�-' f y Contractor performing project n!�L�/V 1 N NO e R�License# l��Exp.Date Lead Paint Inspector 0 �C�,l Date of Inspection -Ll-0 License#i �l,f�D_te '� --� ADDRESS OF PROJECT Street Address i V U \1ON61=94 cc`_Q )�a Apt.Number .p � City .`X4 :,1� �' I `�T—YL 'C,s S Zip 0 a63 Property Owner C hA 4 QJlgn P 1 Address Telephone Number 1}��� ✓ / Deleading Method: Wet/Dry Scraping Heat Gun Liquid Encapsulant Demolition Caustics p eme t -Covering Other it-Other,selected•please explain Check one: Dwelling is multi-family Single-family 1/ {Other Start Date — �_(L_�,, pp Completion Date ! t� When will work he door. AM 1'M (Specify times on site) Weekends? /'h,-7 Project Supervisor Name c K) =0 N o end License#, �<T Exp.Date,, Worker's Compensation Policy *�Number_ r-4- p Carrier In case of emergency contact ).G�/1� /� QV6GQ(�� Tel.#_( �O' 1_�S y `Z�il (Contractor's Representative) DELEADING CONTRACTOR The undersigned hereby states,under the pains and penalties of perjury,that he/she has read and understood the Commonwealth of Massachusetts Deleading Regulations,454 CMR 22.00,and the Lead Poisoning Prevention and Control Regulations,105 CMR 460.000,and that the information contained in this notification is true and correct to the best of his/her Jknowledge and belief. Date �=..,� �.O Signed - �Q 1Company Name_ a," Address Telephone Number7ye f OVER4 i Statements& MCnun•andumS Institute for Environmental Education Regulations Manual C-7_3 06/04 fair 2 of :n arrnrd:iner svith Massaehusetts General Laws C.I11§197,454 CNIR 22.011 and 105 CM It 460.00111.notice of the date and method(s)of rroII.N.A or cnyrr;oi or paint,plaster or other accessible materials containin;,tlangerous It•r els of lead is to he provided and must he received h, IIIe I.M. .in nicncit,.nt least TF.N(III)days prior to the beginning of delcading. MAY BF, f','.XED. I- Delmi-tmeul of Labor and Workforce Development,Division of Occupational Safeh 99 W:i'%hington Street,S'"Floor,Boston,NIA 02108 FAX(617)727-7568 2. Director,Childhood Lead Poisoning Prevention Program Department of Public Health,56 Roland Street,Suite 100,Boston,MA 02129 FAX(617)284-8436 1. Occupants of dwelling unit - d. All other occupants of the residential premises,if any ;- Local Board of IlealthiCode Enforcement Agency G. Massachusetts Ilistorical Commission (if premises are listed on the State Register of Historic 220 Morrissev Blvd. Places,this notification must he made upon receipt of an Ruston.MA 02202 Order to Correct Violations or at(cast 30 daps prior to :1X(617)727-5128 initiating preventive defending) NO rl Pi( ATIONS tit IA Ll.BE COMPLETED iN THEIR F.N7'IRIMY.DATED AND SIGNED-INCOMPLFTE NOTIFICATIONS RILL NOT lit:A(Y E:P rf:1):AND V+'Il.l.BE RETURNED BY THE DEPARTMENT OF LABOR&R°ORhXORCE MVELOPMENT. PROPERTY (NVNER f if nwncr or unlicensed owner's agent will he performing low-risk deleadine work-complete the following): Properiv(loner Agcnt(sj __ .- 'I elephone 6Number_I )- I rcn if m dmal I have complied witlm the training requirements of the Commonwealth of Massachusetts Lead Poisoning Prevention and Control Regulations.105 C'tilh 460.175.for ownedapeni line-risk abatement and containment. i further certify that I or my aecnt will be performing the following low-risk activities (I ha,v circled all that apply): applying liquid encapsulant capping baseboards removing doors,cabinet doors,shutters applying exterior vinyl siding coveting surfaces I ccrtily Ilan all[lie information contained in this notification is true and correct to the bcsl of v k rnvledge and belief. Signed 1)P1I hdic SI;Ilcmenis ct Memorandums Institute for Environmental Educanoll �I;IIC I.�;t(I l:c�'ulati(ms Manual C-74 06/04 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION- v� [ ,. jk C01 f TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMEiNTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM ` PART A CERTIFICATION Property Address: 21 Johnny Cake Road Centerville, MA 02632 Owner's Name: Jennifer Hanlon Owner's Address: jo-t g y' Date of Inspection: September 27, 2005 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Condi 'onally Passes Need urther Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: October 2. 2005 The system inspector shall su4 a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 21 Johnny Cake Road Centerville, MA Owner: Jennifer Hanlon Date of Inspection: September 27, 2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 21 Johnny Cake Road Centerville, MA Owner: Jennifer Hanlon Date of Inspection: September 27, 2005 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 CAM 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. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 21 Johnny Cake Road Centerville, MA Owner: Jennifer Hanlon Date of Inspection: September 27, 2005 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/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 SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 21 Johnny Cake Road Centerville, MA Owner: Jennifer Hanlon Date of Inspection: September 27, 2005 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner, occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS,located on site? ✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ Existing information. For example,a plan at the Board of Health. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 21 Johnny Cake Road Centerville, MA Owner: Jennifer Hanlon Date of Inspection: September 27, 2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): n/a Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 0 Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): Yes Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped on April 27198-per treatment plant Was system pumped as part of the inspection(yes or no): 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)and source of information: Date of installation unknown Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 21 Johnny Cake Road Centerville, MA Owner: Jennifer Hanlon Date of Inspection: September 27, 2005 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction: concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 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: 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: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage, etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 21 Johnny Cake Road Centerville, MA Owner: Jennifer Hanlon Date of Inspection: September 27, 2005 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Cormments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: None (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: None (locate on site plan) Pumps in working order(yes or no): Alanns in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 21 Johnny Cake Road Centerville, MA Owner: Jennifer Hanlon Date of Inspection: September 27, 2005 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 2-6'x 6'(1000 gal.) leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number, dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): Both nits were dry. The scum line in each pit was 3.5'up from the bottom. There did not appear to be any signs of failure The bottoms to Qrade were 10'. CESSPOOLS: ✓ (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: I w/2 overflows Depth-top of liquid to inlet invert: -- Depth of solids layer: 3" Depth of scum layer: 2" Dimensions of cesspool: 6'W x 6'T x 9.5'bottom to Qrade Materials of construction: Cesspool block Indication of groundwater inflow(yes or no): None Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): The cesspool had]'of liquid on the bottom. Outlet tees were present. The cover was 10"below grade. PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 •. Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 21 Johnny Cake Road Centerville, MA Owner: Jennifer Hanlon Date of Inspection: September 27, 2005 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. a 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 21 Johnny Cake Road Centerville, MA Owner: Jennifer Hanlon Date of Inspection: September 27. 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 20+/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maw Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours maps, the maps were showing approximately 20'+/-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied,relating to the system, the inspection and/or this report. 11 TOWN OF BARNSTABLE LOCATION �Ohnn � L �• SEWAGE # VI LLAGE CL i tt•4 1 ASSESSOR'S MAP& LOT oZ 10 - 0417 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY CQSSwo J LEACHING FACILITY: (type) (size) NO.OF BEDROOMS_ BUILDER OR OWNER ���.��"� f r/. e e" PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: r 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 Tunushed by ��1t ta, 4 On , r i"� A ���,�� / 9 '1 i � 6 a 3 / �a. ra a, a3 a� 3 �a. ay COMMONWEALTH OF MASSACHUSETi'S f.Jf EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION �f f ONE WINTER STREET, BOSTON MA 02108 (617)292-5502/ iVEO U� I � i ro4vo8 2440 " Zoe R OXE 'r" Selc'retary ARGEO PAUL CELLUCCI DA ID-B:'STRUHS Governor "" Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 21 Johnny Cake Road, Centerville, MA Name of Owner: Neil Feeley Address of Owner: Smite Date of Inspection: July 11, 2000 Name of Inspector: (Please Print) James M. Ford I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: James M. Ford Mailing Address: P.O. Box 49, Osterville, MA 02655-0049 Map: 210 Telephone Number: (508)862-9400 Parcel. 047 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 Eval By the Local Approving Authority _ Fails Inspector's Signature: Date: July 12, 2000 The System Inspector shall submi 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 the system owner and copies sent to the buyer, if applicable,and the approving authority. NOTES AND COMMENTS revised 9/2/98 Page Iof11 Printed on Recycled Paper • ` r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 21 Johnny Cake Road, Centerville, MA Owner: Neil Feeley Date of Inspection: July 11, 2000 INSPECTION SUMMARY: Check A, B, C, or D: i A. SYSTEM PASSES: ✓ 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: 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 Y � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 21 Johnny Cake Road, Centerville, MA Owner: Neil Feeley Date of Inspection: July 11, 2000 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 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 THE PUBLIC HEALTH AND 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 AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet to 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 revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 21 Johnny Cake Road, Centerville, AM Owner: Neil Feeley Date of Inspection: July 11, 2000 D. SYSTEM FAILS: You must indicate either"Yes" or "No" as 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/z day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the 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. 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. 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: You must indicate either"Yes"or"No"as 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 H 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 Page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 21 Johnny Cake Road, Centerville, MA Owner: Neil Feeley Date of Inspection: July 11, 2000 Check if the following have been done: You must indicate either"Yes" or"No" as to each of the following: Yes No ✓I _ Pumping information was provided by the owner,occupant,or Board of Health. ✓ _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. n/a As built plans have been obtained and examined. Note if they are not available with N/A. ✓ _ 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. ✓ _ The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for conditions 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: ✓ Existing information. For example, Plan at B.O.H. Determined in the field if an of the failure criteria related to Part C is at issue approximation of distance is unacceptable) _ ( Y PP �P ) [15.302(3)(b)]• ✓ _ The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5of11 y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 21 Johnny Cake Road, Centerville, MA Owner: Neil Feeley Date of Inspection: July 11, 2000 FLOW CONDITIONS RESIDENTIAL: Design flow: 110 g.p.d./bedroom. Number of bedrooms(design): n/a Number of bedrooms(actual): 4 Total DESIGN flow n/a Number of current residents: 2 Garbage grinder(yes or no): Yes Laundry(separate system)(yes or no):No If yes, separate inspection required Laundry system inspected(yes or no): Yes Seasonal use(yes or no): No Water meter readings, if available(last two year's usage(gpd): 1999-118 000 gals.:1998-116,000 gals. Sump Pump(yes or no): No Last date of occupancy: Gyrrently occupied COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: apd(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: Pumped on April 27198-per treatment plant System pumped as part of inspection(yes or no): No If yes,volume pumped: gallons 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) UA Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components,date installed(if known)and source of information: Unknown Sewage odors detected when arriving at the site: (yes or no) No revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 21 Johnny Cake Road, Centerville, MA Owner: Neil Feeley Date of Inspection: July 11, 2000 BUILDING SEWER: _ (Locate on site plan) Depth below grade: Material of construction: _cast iron _40 PVC _other(explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints,venting,evidence of leakage,etc.) SEPTIC TANK: None (locate on site plan) 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,structural integrity, evidence of leakage,etc.) GREASE TRAP: None (locate on site plan) Depth below grade: , Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: 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 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 21 Johnny Cake Road, Centerville, MA Owner: Neil Feeley Date of Inspection: July 11, 2000 TIGHT OR HOLDING TANK: None (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 BOX: None (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: None (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order: (Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 21 Johnny Cake Road, Centerville, MA Owner: Neil Feeley Date of Inspection: July 11, 2000 SOIL ABSORPTION SYSTEM(SAS): ✓ (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: 2-6'x 6' leaching chambers, number: leaching galleries,number: leaching trenches, number, length: leaching fields, number,dimensions: overflow cesspool,number: Alternative system: Name of Technology: Comments: (note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.) Both pits were dry. The scum lines on both pits were 3'6"up from the bottom. There were no signs of failure. The bottoms to grade were 10'. CESSPOOLS: ✓ (locate on site plan) Number and configuration: I with 2 overflows Depth-top of liquid to inlet invert: 2' Depth of solids layer: 3" Depth of scum layer: 2- Dimensions of cesspool: 6'W x 6'Tx 9'6" bottom to grade Materials of construction: Block Indication of groundwater: None inflow(cesspool must be pumped as part of inspection). Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.) The cesspool had 4'of water on the bottom. The outlet tees were present. PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.) revised 9/2/98 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 21 Johnny Cake Road, Centerville, MA Owner: Neil Feeley Date of Inspection: July 11, 2000 Map: 210 Parcel: 047 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 Aa- 03 a3- ay revised 9/2/98 Page 10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 21 Johnny Cake Road, Centerville, MA Owner: Neil Feeley Date of Inspection: July 11, 2000 NRCS Report name Soil Type Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property,observation hole,basement sump etc.) ✓ Determined from local conditions ✓ Checked with local Board of Health Checked FEMA Maps Checked pumping records Check local excavators, installers ✓ Used USGS Data Describe how you established the High Groundwater Elevation. Must be completed) The bottoms of the pits to grade were 10'. Using the Barnstable topographic map and water contours map, the maps were showing approximately 20' +/- to groundwater at this site. Using the Cape Cod Commission Technical Bulletin, the high groundwater adjustment for this site(AI W 247, Zone C, 5100)was 5.5'. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. revised 9/2/98 Page 11of11 i TOWN OFBARNSTABLE OCATiO'iv' 01 �)O.�n^`i \. A�c R d SEWAGE # VILLAGE UIG✓1TCrV� ASSESSOR'S MAP &LOT IO 01I1 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY S S P-00 I LEACHING FACILITY: (type) o� — P tTS (size) x NO. OF BEDROOMS_" BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private,Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by r At- Wk a 3 ' ay ' , Al- 6 a g3- ay a 3 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PRO IVED SEP222003 TOWN OF BARNSTABLE HEALTH CREPT. TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 21 Johnny Cake Road Centerville, MA 02632 MAP ZI 1 Owner's Name: Robert Fraser Owner's Address: PARCEL -.-- Date of Inspection: September 9, 2003 LOT2 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O. Box 49 Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Need urther Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: September 11, 2003 The system inspector shall sub ' a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 21 Johnny Cake Road Centerville, MA Owner: Robert Fraser Date of Inspection: September 9, 2003 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined(Y,N,ND) in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box.. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 21 Johnny Cake Road Centerville, MA Owner: Robert Fraser Date of Inspection: September 9, 2003 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. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 21 Johnny Cake Road Centerville, AM Owner: Robert Fraser Date of Inspection: September 9, 2003 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either`yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 21 Johnny Cake Road Centerville, AM Owner: Robert Fraser Date of Inspection: September 9, 2003 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks ? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection ? ✓ Were as built plans of the system obtained and examined ?(if they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out? ✓ Were all system components,excluding the SAS, located on site? ✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions, depth of liquid, depth of sludge and depth of scum ? ✓ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ Existing information. For example, a plan at the Board of Health. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 Page 6 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 21 Johnny Cake Road Centerville, MA Owner: Robert Fraser Date of Inspection: September 9, 2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): n1a Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 1 Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system (yes or no): No (if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIALIINDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped Apr. 27198-per treatment plant Was system pumped as part of the inspection (yes or no): 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)and source of information: Unknown Were sewage odors detected when arriving at the site(yes or no): No 6 r 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: 21 Johnny Cake Road Centerville, MA Owner: Robert Fraser Date of Inspection: September 9, 2003 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting, evidence of leakage,etc.): SEPTIC TANK: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of cum 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: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 7 Page 8 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 21 Johnny Cake Road Centerville, MA Owner: Robert Fraser Date of Inspection: September 9, 2003 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX: None (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: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 21 Johnny Cake Road Centerville, MA Owner: Robert Fraser Date of Inspection: September 9, 2003 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits, number: 2-6'x 6'(1000 gal.) leaching chambers, number: leaching galleries, number: leaching trenches, number, length: leaching fields, number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): Both pits were dry. The scum line on each pit was 3'6"up from the bottom. There did not appear to be any signs of failure in either pit. The bottom of the pits to grade was approximately 10'. CESSPOOLS: ✓ (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: 1 w/2 overflows Depth -top of liquid to inlet invert: 4' Depth of solids layer: 3" Depth of scum layer: 2" Dimensions of cesspool: 6'If 6'T x 9'6"bottom to grade Materials of construction: Cesspool block Indication of groundwater inflow(yes or no): None Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): The cesspool had T of water on the bottom. Outlet tees were present. The cover was 10"below grade. PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 9 Page 10 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 21 Johnny Cake Road Centerville, MA Owner: Robert Fraser Date of Inspection: September 9, 2003 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. a Q a3 aY 10 Page 1 1 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 21 Johnny Cake Road Centerville, MA Owner: Robert Fraser Date of Inspection: September 9, 2003 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 20 +1- feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record- If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: The bottom of the pits to grade was 10'. Using the Barnstable topographic map and the Cape Cod Commission water contours map, the maps were showing approximately 20'+/-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report.