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HomeMy WebLinkAbout0415 NOTTINGHAM DRIVE - Health 415 Nottingham Drive Centerville P A = 148 023 No.42101/3 ORA d 10®l0` ® © p 1 TOWN OF BARNSTABLE LOCATION 466� rI,�� c SEWAGE # VII`.LAGEE [ , V44 ' �P ASSESSOR'S MAP & LOT 4ER'S NAME&PHONE NO. S d SEPTIC TANK CAPACITY C� . LEACHING FACILITY: (type) / (size) NO.OF BEDROOMS /J_ BUILDER OR,OWNER WPC SOCK t 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 f» i � .� � �� .�a��, �/ /�/p�' ��Mt � ,. #�. J .. �.. �„ /,�' ►...:�! COMMONWEALTH OF MASSACHUSETTS RECEIVED EXECUTIVE OFFICE OF ENVIRONMEN'i'AL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION J U L 15 2003 u lu4wly OF BARNSTABLE e HEALTH DEPT. o, ,e TITLE 5 OFFICIAL INSPECTION FORM -NOT FOR VOLUNYARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 415 NOTTINGHAM DRIVE CENTERVILLE, MA 02632 Ii 10 Owner's Name: BILL& DONNA DONLEY Owner's Address: 415 NOTTINGHAM DRIVE CENTERVILLE, MA 0263-1 Date of Inspection: 6/17/03 Name of Inspector: (please print) JOHN GRAC1, INC. Li Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 2119 TEATICKET, MA. 02536 Telephone Number: 508-564-6813 FAX 508-564-7270 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: X Passes _ Conditionally s s _ Needs Furthe luation by the Local Approving Authority Fails Inspector's Signature: Date: 6/17/03 The system inspector shall submit a' opy of this inspection report to the Approving A.cthority(Board of Health or DEP)within 30 days of completing this inspecti . 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 SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING NOW AND THEN EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. ****This report only describes conditions at the time of inspection and under th, 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. Till.• ; r....„•, fi,- r.„„. r,I s»nnn i Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 415 NOTTINGHAM DRIVE CENTERVILLE,MA 02632 Owner: BILL&DONNA DONLEY Date of Inspection: 6/17/03 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X 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: SYSTEM PASSED TITLE V INSPECTION.RECOMMEND PUMPING NOW AND THEN EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. 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. n/a 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: n/a n/a 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: n/a n/a 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: n/a Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 415 NOTTINGHAM DRIVE CENTERVILLE,MA 02632 Owner: BILL& DONNA DONLEY Date of Inspection: 6/17/03 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 n/a "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: n/a Page 4 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 415 NOTTINGHAM DRIVE CENTERVILLE,MA 02632 Owner: BILL&DONNA DONLEY Date of Inspection: 6/17/03 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped NO PUMPING INFORMATION. X Any portion of the SAS, cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X 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 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 X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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: 415 NOTTINGHAM DRIVE CENTERVILLE,MA 02632 Owner: BILL&DONNA DONLEY Date of Inspection: 6/17/03 Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant, or Board of Health X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? _ X Have large volumes of water been introduced to the system recently or as part of this inspection ? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out`? X _ Were all system components, excluding the SAS, located on site? X _ 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? X _ 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 X _ Existing information. For example,a plan at the Board of Health. X _ 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: 415 NOTTINGHAM DRIVE CENTERVILLE,MA 02632 Owner: BILL&DONNA DONLEY Date of Inspection: 6/17/03 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Number of current residents: 2 Does residence have a garbage grinder(yes or no): NO 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)): Q t „ wo®0 Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: NO PUMPING INFORMATION Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X 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): n/a Approximate age of all components,date installed(if known)and source of information: 1980 BY OWNER,NEW 1990 Were sewage odors detected when arriving at the site(yes or no): NO C Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 415 NOTTINGHAM DRIVE CENTERVILLE,MA 02632 Owner: BILL&DONNA DONLEY Date of Inspection: 6/17/03 BUILDING SEWER(locate on site plan) Depth below grade: 36" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints, venting,evidence of leakage, etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 30" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a IF--;e confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000 GALLONS_ r Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 4" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 14" How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING NOW AND THEN EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): n/a Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 415 NOTTINGHAM DRIVE CENTERVILLE,MA 02632 Owner: BILL&DONNA DONLEY Date of Inspection: 6/17/03 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction: _concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches, etc.): n/a DISTRIBUTION BOX: X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE 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.): D-BOX IS STRUCTURALLY SOUND. PUMP CHAMBER: _(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): n/a R Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 415 NOTTINGHAM DRIVE CENTERVILLE,MA 02632 Owner: BILL&DONNA DONLEY Date of Inspection: 6/17/03 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF FAILURE.PIT HAS 16" OF LEACHING LEFT IN IT. BOTTOM IS AT 11 FT. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a A " Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 415 NOTTINGHAM DRIVE CENTERVILLE, MA 02632 Owner: BILL& DONNA DONLEY Date of Inspection: 6/17/03 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. w� . �° 2N � � i in Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 415 NOTTINGHAM DRIVE CENTERVILLE,MA 02632 Owner: BILL&DONNA DONLEY Date of Inspection: 6/17/03 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12 +feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record- If checked, date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: HAND AUGER- 12+FT. "D COMMONWEALTH OF MA,SSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIR.9 DEPARTMENT OF ENVIRONMENTAL FRO'TEC'TIO;I,' TITLE S OFFICIAL IN31"ECTION FORM—NOT FOR VOLUNTARY ASSESSM]EN'T' SUBSURFACE SEWAGE I1ASPOSAL SYSTEM FORM PART A CERTIFICj!►TION property Address: Di— Owser's Name: 1 t Chwur's Address:— /-.5 k �1 r Date of Iaep edn:,_j 4jL e m s Name of Inspector.(Plan print), �`� ee _ Company Names er "b!>�tt 1,-s fechooLs Mailing Address: Telephone Numbest: .Ems GAS G.Cf f p �..'1I2 18• 76 6 8 CERTIFICATION 24 T.ATEMENT I certify that I have petbon,tlly inspected,the sewage disposal s;%Um at this address and that the information porked below is true,accurate and c4:,mplft as of the time of the inspe etion.The inspectie�was performs based cc. po training and experience ny in SAP,proper function and mainteuanct,of on site sewage disposal systems.I am a D P approved system inspector ipursuaat fro Section I5.340 of Title S(310 CMR 15.000). The system: passes �.. Conditionally Passe:, Needs Further Evaluation by the Local Approving Autbority Fails Inspector's Signatunt: ."0' .� Dates. The system inspector shall rubmit a copy of4his taspectfon i,epsrt to the Authority DEP)within 3o days of coat;detiag this, If the syta P' is a shared (Board of Ii.calc i,or 9Pd or greaser,the inspector acid the system owner shall submit the report to or has a design flow of ltl,:OQ DEP. The orioaal should he glmt to the cl,atem owtaer a0d copilxt sent to the bu appropriate�.otlal COMM.01"!lie authority, ym� applacabit,and the 4ppror, Notes and Con=ents ""This report only desert lms conditions at the time of inspection and under the conditions of use at t1�I,t titan. This inspection does not address tj)w the aye will pea�form is the hrtare under tAe coaditbns of rase. a""or diis.,riat Title 3 Inspection Foray 6/1�i/2000 n.s. i Page 2 of l l OFMCIAL INSPECTION FORM--NOT POOR VOLUNTARY ASSFMmmwn SUBSURFACE SIMIAGE RISFOSAL S'YSTEm INSIECTION FORM �.� PART A C MnFICATi W(mdnued) Property Address: i 5 turner: tpa Date of h I11111me s Summsaary: Cheek AAC,D or Z/AkVJ=ee saplee all of Seeaims D A. System Fusee: I have not found my information which indicates flint i ny of the fa4wv criteria described in 31013-11I 15.303 or in 310 CMR 15,304 exist.Any failure criteria not ev duated are indicated below. Comments:- f:'• e.7 .�... ... IL System Condidomall;,Panes: One or more system component as described in the o>aditiomal Pass"section need to be replacesi m- repaired.The system,upon.asmpledon of the replacemen n pair,ss appmod by the Hoard of Heap,will ;ass. Answer yes,no of not detemmined(Y,N,ND)in the for tho following statements.If't&determined"pk; ee explain. The sgtk tank is m,nd and over 20 old"or the septic tank(whether metal or not)is smwuuall.y unsound,exhibits substanti sl iafllt etion on or tank!Mum is imminent,System will pass isaspe;�ct,:';e i if file existing tank is,replaced with a complyir sepda is I as i!pp w,*d by the Board of Health. 'A mead septic tank will pits a inspect! .if it is strueturaDy set,nd,not leaking and if a'Cert ficat of Cort,pliisa :e indicating that'the tank is Ir, e.than 2 srs old is availabk. ND��' tbservsdion of sewi!ge or braak W,or i�SWa;water level in the distribution box due to broi ;m air obstructed pipe(s)or due tc, broken.soiled or mom distrdwlion box. System will pass hgmction if(, it ' approval of Board of Heat ! . broken ob�nsetistt )mstvve + distxleetisaf bet Is Imiekd it replaced ND explain: The syst requited pemtpiag mcr+e than 4 times a year dus to broken or obstructed pipe(s).The syraresr !rill pass inspection if(with approval of the Hawed ofHn*)° .�bnoke`n pips(,)are replaced obee nmdon is removed ND explain: 2 r Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSISSMFI 'S SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM PART jk CERTIFICATION(eootinued) Property Address: Owner. : s .Date of I :I:.;�0�. C. Further Evaluation Pi F*quired b;p the Board of Hearth: Conditions exist wHcli require fi:rtber evaluation by tho Board of Ith in order to determine if%he s, stern is failing to protect public:::ealth,safety for the envitonamt. I. System will pan val4a Board of Health determines lire rdance with 310 CMR 15303(1�:b)t1!it the system is not tafte loning in a n:eaaaer which*10 prte public health,selety and the envitenasP ;et: Cesspool ar'jx-iv)f is within a0 fief of A fer - Casspooi or pr;v),is ivitblti;i0 fw of a �,vSetsted wetland or a salt h 2. System will fail urn!�ess the Boaer of Health(and Pub lilt Water Supplier,if any)determines that;t e System is ft,nedoning lids manner t protects the public basith,safety aad eavironment: , The system has a septic ;and soil sbsorptiaa sliftm(SAS)and the SAS is within 100&v:of., surface water supply or trio 10 a AUri�=water imrlY. ` The;system he,s a: tic tanl:and SAS and the SAS,is within a Zone I of a public water supply. Ilse sys"Pt,W'�!septic tank:end SAS ate the SAS,is within SO feet of a/ �ivme Water supply an.l 1. The system he a septic WA:and SAS and the SAS is less than i00 feet but SO feet or more heat;, private vrater supp u►teU*•.Metbod used to determine distance "This system p ssa: .it'the well water analysis,performcd at a DEP certified laboratory, for colifuroa the presence emd vo 7e Pxrfpnnic compounds indiptes beat th a well is free from pollution from that facility P iid the presence amaumi:a nitsogeri and nitrate nitrogen Its equal to or less than S pprn,provided tb=:mo a ilia failure c ' are trillgtnd.A copy of the aoalyjU,a!uac be atosched to this form, 3. Other. Past a of i l OMCIA L DISPECTION FORM—NOT FOR VOLUNTARY ASSESSlf 1.1ul i SUBSUPW44E SEWAGE .:SVSTEM INSPECTION FO"I PART-A- CERTINCATIfD:N(cow) Property Adduces: Owner: Date of D. Systess JFidere Criteria applicable to ON systems: You AM Wlicste"yes" c r"no"to tfac,h of the following f br ilL Yes No _ a Ll Backup of sa ioaite into faciLty or,system compommit due to overloaded or clogged SAS or coa;jw:1 Dischltrge or I)aoding'of effluent t�the surbAe of the ground or surface vt►aters due to an owl l«A A cs, clogged SAS ar cesspool ; Statie liquid level its the&9ribution box above 6irdat invert due to�overloaded or clogged SA.,! or cesspool t r Liquid depth its rasspool is leas than 6"below invazrt or available volume is less than�1K day flaw Reared pumldtag more ttsun 4 tgnes in the last y4w N=due to clogged or obstructed pipeis;i. 1, =12cr of Haines pumpai Any portion ol'ttbe SAS.catispool or privy is below high ground water elevation. Any portion ol'cissspooi or privy is within 100 feet:of a sutrlhee water supply or tributary to a surf: v wow supply. Any portion al'a cesspool or privy is witch a Zaea 1 of a jublic well. . Auy portion a!'a cesspool at,privy is within 50 fleet of ptrivato water siipply well. Amy portion oi''a cesspool ar privy is lea than 100 feet bit greater than So feet from a private was i,r M3PP1Y well w&no acoeptttblo water quality atsahisip,j3°hb system passes if the well watar.saulysbt, perNrmed at a DEP certlltied-labera tery,tflmr m,llillam bacteria atad volattik organic eoattptat;1 ds ledleat"that:tilt Wall b fires front pofJsttloo Proia ttb0 fheRhy mad the presence of ammonbi i(tcogea lied siittate nitrogea b agaaai to•or has dM2 A pPs,provided that ttto ofter..hasre l iteirla are triggered AL copy of die analyab WSW be,ANIS hed'ft"form] _(Ye slNo)The cyst esis fWlit,I he ve determined that one at more of the mbovc-faiiure'crisis,exist as described in 310 C&M 15.303,theE ftre the ttystee=&HL The system owner should contact the EI and of Health to deac mine what will be necessary to writ set the failure. L Large System To be comMered a e k"g Them the a,y:teae aged ttory with m 1i �?' 1Soir of]l 800 You must indirAw either 6�is"or"non tj)atttcd of ; ('The following;a feria apply to WV sylaw addition to the cdwia ab ove) yes no the system is wit]tir,400 f a surfisoe drlolcing water supply ® the VAM is will dt�2 olr a tributary to a sarfacit&Wking water supply the system is loc Wil in a nbroilen sensitive area(interim Wellhead Protection Area—IWPA)or a,al. ppeli Zone 11 of ie•watt supply well Ifyou have anawerZe tte-any question in Section E the sysisam is considered a "yes"in Section De large systeu:has failed.'I]re owner or s'g° 'cr era"t"' end opt of any large syenssn considered tt sigarilacaat threat seeder Secdcas E or fisikod under Section D shal_ ac !upgrade she system in eardence With3:10 c. Ot 15.304.'Ihe system owner,should contact the appropriate r*etrtsl of ke of the Department. Page S of i l OFFI(M4,L INSPECTION FOAM—NOT FOR VOLUNTARY ASSESSM1M1!:1 SIOSSURF'.ok E SEWAGE DISPOSAL SYSTEM[INSPECTION FORM PART 1H CHECKLIST Propeq Address: y 15 Owner: l ®etc of tau a° C? .Check if the fallowina bay bee�iY You not indiew"Ye:"or"no""to each of the Mo:! �%: Yes No Pumping infonmation was ptcvidrd by the owner,occup"t,or Board ofHeabb Were any,of the system components pumped out in Ike previous two weeks? Has me system n+eceived nor ud flows in the pcevieaa two week period? _ Have large volinxiea of water been int Awed to the ov=recently or as part of this inspection __„ Were as built planes of the system dbtsined and exainined?(If they were not available note -a NtIK Was the facilit,or dwelling bwpected for signs of aewaga back up'? , Was the site imgw-aed for signns of break out? Were all s stem Conn /..�. .�... y pohents,excluding the SAS,l(>s:ated on site? ,. Were the septic tsak'manhobes uncovered,opened,and the interior of dw task-inspbad for the:ow Ution +016 ba!&es or-"' .,mateHal bf constnictiou,dinumi ®s,deFtiti of liquid, of sludge�d 9m depth $ depth of setae a" Was the facilitj 1)%mer(and(k:cupaats if different Jltaa owner)provided with information on tips N ';11 er ce of subsu_rfaar'aeav►age diwisal systems? The sire end 1MtJ(sl of the Sail Absont oR System ;SAS)on the site has bees detertnized bawd eau: Yes no E Existing taforrn a io®.For cunnple,a plan at tree Board of Health. _ Dexenmuned in tlte;i9!eld(if on•y of the fAilure criteria restated to Part C is at issm approximatiorn c,f rl a i atnas is eptablc}(310 CA�IIt i.3.302(3)(b)J r Fade 6 of i l OM461AL DISPECTION FORM--NOT FOR VOLUNTARY ASSESSWIN—.ii SUBSUIVACE SEWAGB-0ISPOSAId SYSTEM INSPECTION F'ORAI PART C SYSTEM INM114MATION Property Address; : Owtmer: Data of : ,F ow CONDITIONS RESIDENTIAL, Number of bedrooms(dssyp):.ta Nmber of bedrooms(&moil): DESIC}N flow based on lU CM! IS 2D3(for example: I Io;`pd x N of bedrooms): -3�0 Number of owr nt reQec01..,—a Don raaideace brave s darbtp grip(yea or noj:Orb It laundry on a separate hevinAge sY `(yes or no):' (if y:es separate inspection required] LaUn y system !{ or no):,W (�d Seasonal use:(yes or no): / Lau date of=upmy:l i af�T TO U:i?1tIAL Type of eheabliahout: Desip Sow(based on 31; (:MR I 3): mod Basis ofdsaiidn now(esul/m g,ac,); i Oran vap pr+uent(yea at a . bdustrial wahae holding u4;prey(yes or no): on-smitary WOO iBiid to the T,als.s sysMm(yes or no,. Waver cuter trainable: — ` Lou date of Am!: OTHERKJA�AG f G:I1rNERAL PumpkasAftords INPORMA,TION Source of information: 02112 ` Was sy"=pumped as—':a.f the' Q 4`c Rid If par ump°': (ya or ao): yes,volume pumped: R+eahan for lumPbd: ,W How was quantity pu uped determined? _..._�...�_ TY .,,?Z OF SYSTEM Sites � cash; iatL box,soil&WWpd=ayaosm Overflow cehopool ..Shand syststa(yes or o o)(if yes,atuWh pt+hviotu h10P@0dW MOW*.if any) IanovatiVW,4lbW=dVe i hcibaoloV.Mach a copy of the curt Int operation and maintenance contract(ar be obtained ftm s,yhssm owaw) —Tight tank —Anact.a CIPPy of&u DEP approval ,,,,,Other(describe): Approximate age of all cony:a:ants,date installed(if known)as:l source of information: Were sewsde odor detecoed wtarn atriviali at the the(yes or no): �r Page 7'of l 1 OFFICIAL IN 51MCTION FORM—NOT FOR VOLUNTARY ASSESSMENT: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORtMI. - PART C SYSTEMghNFORMA.'TION(continued) Property Address.A,!r'ad' . ` � .ate Owner: �_ Date of Insp�;,J, Q BUILDING SEWER(10:00 an Alec plan) Depth below grade: 31 r _ Materials of construction:_ east iron _L40 PVC other ;explain): Distance&a m private was er supply well or suction line: Comments(on condition i ff,joiata,venting,evidence of leakge,etc.): N. SEPTIC TANK:L(to:atie at site plim) Depth below gmde: 1_ Material of co :.i.poncteoa_,weal Sberglats ..._polYethYlene —other(explain) _ If tank is areal list age:__ Is age cottira:ed by a Certificate,of CoIDopliance(yes or no):`'(mach a copi )f eerto) Dimensions: Sludge depth'.... !� Distance from top of sludge to bottom of outlet tee or baffle: Scorn thickness: - Distance&oax to . tap of Ater..to of oud�et tee or battle: Distance from,bottom ofs:uto to bottocipf outlet tee ` How were dimemlow deb J:ruuned:_ d bsd�e: _ Comments(on pumping ro-oinmendations,inlet end outlet tee or battle condition,structural inv inte d outlet ert,ovielenee of les�cage grity,li�lur�f ;vela; .�aws rela!! w GREASE TRAP:1poeste on site plat) _ Depth below grade: Material of cones; cea"M -rmeal -_—pot►ylene`Doer (explaia): _ Diamnsions: ------ - Scum thickness. -- Distance from top of atom u�top o ;t:tee or battle: Distance ftm bottom of scum of outites tee or baffle: Date of last pwnping: -- —_-- Comments(on pumping xearn y inlet Arad outlet tee(N.baffle conditii as related to outlet inv e•n.druce of leakage,ec.): °n' integrity, B Y.114 JU sl.la a els Page 8 of 11 OFFICIAL WSPECTICON FORM d NOT FOR VOLUNTARY ASSESSME:W is SUBSURFACE SE/WAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM tWORhL%.TION(continued) Property Address: Dots of •:J � TIGHT or HOLDING'tANK: (tank must be pumped i:t time of inspectionxlocats on sift plan) Depth below Brads: Material,of construction: _—concrete, fiberl.1"s polyethylene other(sxplaia): Dimensions: Capacity:—. ._ Design Flow: clwday Alarm Plasm ryas or no):_ Alarm level: Ali, in waeftwS order(yes or no);_ Dame of last pumping: Conzmeaa(condition jilaim sad iioat switches,etc.): DISTRIBUTION BOX:A•. (if womrnt must be— opaaed)(la:fie on site plan} Depth of Squid level abovr,outlet invent: Comments(mate if box is aetiel and diam•dbtttloa t leakage t of etr.. : 9 outlets equal,any evidence of solids carryover,my evider:is of ' o or o PUMP CHAMBER: Clocate on s' in wft*� norder - —_ Pumps g order(y to n o :. Alarms in wmim order , es or no):� Comments(note c on of pump china r,condition of ,. puorias and aces,sac.): --� Page 9 of it OFFICIAL INSPECTION FORM—NOT]FOR VOLUNTARY ASSESSM ]1Cr!,, SUHSURY4CE SEWAGE DISPOSAL. SYSTEM INSPECTIO14 FORM' PART 1 SYSTEM IMRNIA nON(continued) Property Address NV4g Date SOIL ABSORPTION S:tSIMM(SAS:): poeate on site plan,e:eavation sm required) If SAS not located expl161 w:h-y- : F" s Jjk T lemming piib,nuntbos^ ieaddas ciambers,auw*er: leaching galleries,nud)w: leaching trenches,number,teno: leaching fields,nutnter,dimensions- _ overflow c asspool,touri:bar. innovativelalternafliv system Ty;**me of wftology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of v,gott.i on, etc.): CESSPO®LS: . (cest a gal moat be iunped as of iasnection)(locate on site plan) Number and ecifiguratiorl: Depth top of liquid W—bbit iatvert: Depth of solids layer. ,. Depth of scum layer: �— Dimensions of cesspool: Materials of construction: Indication of groundwamd2flow(yes or no): r.a Comments(note on o> moil,signs of hydraulie,faiiuse,h.rvl of pondiag,condition of vaptadon,etc..): PRIVY: (locate on&.ts I�lstr) Materials of c Dimensions: atructton: _� ---- Depth of solids: Comments(note: tion of ioil.sighs of hydraulic failure.Irnd of pondW&condition of vegetation,� a atc:.); ti Page 10 of 11 OFFICIAL WHRECTION FORM-NOS°:EOR VOLUNTARY ASSESSMENT; ► SUBSUW 4,CE SEWAGE OISPOSAL,SYSTEM INSPECTION FORM PART tr SYSTEM WORMA TI®N(continued) Property Address: 1(l vs_`0 s1� P^it k Owner: ; - Date of Ls a:.a� rjin�'d/ SXETClI OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the wA,a6,,e disposal system including ties'b)at least two permanent refrence landwa is 1: benchmarks. Locate all wo ilo within 10+D feet.L Acata when p19Ak water supply enters the building. y� Page 11 of 11 OFFICIAL IN.,;ImECTTON FORM—NOT TOR VOLUNTARY ASSESSME:IV7C!i S'USSURF,krlfi'SEWAGE DISPOSAL SYSTEM INSPECTION,FORM PART+C' SYSTEM INFORMA'TION(continued) Property Addram: 15 s � Owner: Date of App-e. , SrM EXAM Slope surface*afar Cheek cellar Shallow wells Estimated depth to grounc.hider_ :feet Please indicate(check)all mathods used to determine the high ground water elevation: Obtained ftm sy as design plena on record-If checked,date of design plan reviewed: Observed site(ab+attag;property/ca ration hole within 150 fee of SAS) Checked with local Hoard ofHealth-explain: _ Checked with local�ccaswators�ia3ta11 s-(attach doc kunintstion) e:Accemedl USGS datibate-explain; ' u s*S W You most desk how you established the high ground water slevstion: 14 TOWN OF BARNSTABLE LOCATION Y SEWAGE # VYi,;LAGE ASSESSOR'S MAP & LOT/Y-Lf)j INSTALLER'S NAME&PHON E NO. i SEPTIC TANKTANK CAPACITY t 0 a LEACHING FACII.ITY: pe) (size) e NO.OF BEDROOMS (� .BUILDER OR OWNER l) 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 an y W;�) xist within 300 feet of leaching facility) Feet Furnished by uJ