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HomeMy WebLinkAbout0186 PATRIOT WAY - Health l 86 PATRIOT WAY, CENTERVILLE A= 193198 Il/l �QEcvC�fer UPC 12543 NOS HASTINGS,MN f i93- 1(?9 Commonwealth of Massachusetts Title 5 Official Inspection Form -- Subsurface Sewage Disposal System Form=Not for Voluntary Assessments r, 186 Patriot Way Property Address Hasz Realty Trust, Victor Hadawar Trustee Owner Owner's Name �.�.....� �,_.,....�....._ ' information is required for every Centerville ✓ Ma _ 02632 6/27/2018 page. City/Town State Zip Code Date of Inspection p� r�7 Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, llt use only the tab 1. Inspector: key to move your cursor-do not. Sean M. Jones use the return Name of Inspector � - key. S.M.Jones Title V Septic Inspection Company Name _ -- 74 Beldan Ln. Centerville Ma 02632 City/Town State _ Zip Code 774-248-4850 smjonestitle5@gmail.com SI4522 Telephone Number W License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ❑Q Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 6/27/2018 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and.under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. 15ms•3/13 Title 5 Oftiat Inspection Form:Subsurlece Smoe Disposal System•Page 1 of V Commonwealth of Massachusetts a - =_ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 186 Patriot Way Property Address Hasz Realty Trust, Victor Hadawar Trustee Owner Owner's Name information is Centerville Ma 02632 6/27/2018 required for every page. Cityrrown state Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The dwelling located at 186 Patriot Way Centerville is served by a Title V septic system consisting of a 1000 gallon septic tank, distribution box,precast 1000 gallon leach pit and 4 Infiltrators. The system was found to be in proper working condition at the time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes', "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): I 15ms•3N 3 Me 5 Official tnspechon form:Subsurface Sewage Disposal System•Page 2 of 17 r Commonwealth of Massachusetts - • Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments 186 Patriot Way Property Address ' Hasz Realt Trust, Victor Hadawar Trustee Owner _ _ _M Owner's Name information is Centerville Ma 02632 6/27/2018 required for every �...�..�..,. _. ...,... .,.__ page. Cityrrown State Zip Code Date of Inspection B. Certification (cont) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: El Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 official tnspection Fomv SubstiAam Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts = � Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 186 Patriot Wad Property Address Hasz Realty Trust, Victor Hadawar Trustee Owner Owner's Name information is Centerville Ma 02632 6/27/2018 required for every - page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: •' This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ z 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 ❑ z Liquid depth in cesspool is less than 6" below invert or available volume is less than Ya day flow t5ms.3113 Tide 5 Official Inspection Farm:Subsurface Sewage Olsposat System•Page 4 or 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 186 Patriot Way , Property Address Hasa Realty Trust, Victor Hadawar Trustee Owner Owner's Name information is Centerville Ma 02632 6/27/2018 required for every � page. CitylTown State Zip Code Date of inspection B. Certification (cont.) Yes No ❑ Q Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Q Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Q 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. ❑ X Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Q Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ Q The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ Q 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 16,000 gpd. For large systems,you must indicate either"yes"or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area_ IWPA)or a mapped Zone Il of a public water supply well If you have answered"yes'to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 official inspection Form.Subsurface Sewage Disposal System•Page 5 of o Commonwealth of Massachusetts WA Tithe 5 Official Inspection Form -- f° Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .. 186 Patriot Property Address Hasz Realty Trust, Victor Hadawar Trustee Owner Owner's Name information is Centerville Ma 02632 6/27/2018 required for every ,�� ..a._.,.. page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? Q ❑ 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? Z ❑ Was the site inspected for signs of break out? ❑ 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? Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information, For example, a plan at the Board of Health. ® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 - DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 30 gpd 15ins,3113 Title 5Othom Inspection Form:Subsurface Sewage Disposal System-Pape 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form = Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .. 186 Patriot Way Property Address Hasz Realty Trust, Victor Hadawar Trustee OwnerOwner's Name �""'�'».. _.._. .-.......__....,M._k.._.�_._.___.�.....,._._.�...._.._..........._._._ Information is Centerville Ma 02632 6/27/2018 _ required for every page. CitylTown State Zip Code w Date of Inspection D. System Information Description: Number of current residents: 2 ---- Does residence have a garbage grinder? ❑ Yes 0 No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes © No Water meter readings, if available(last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions. Type of Establishment: Design flow(based on 310 CMR 15.203): Gallonspe�day(gpdj Y � " Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: i5 ns•3113 Tine 5 Offidai Inspection Gam Suburface Sewage Oisposet System Page 7 of 17 Commonwealth of Massachusetts _ r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 186 Patriot Way Property Address Hasz Realty Trust, Victor Hadawar Trustee _ Owner Owner's Name information is required for every Centerville Ma 02632 6/27/2018 page. Cityrrown State _ Zip Code Date of Inspection D. System Information (cone.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: --- - - ---� Was system pumped as part of the inspection? ❑ Yes 0 No If yes, volume pumped: gallons " How was quantity pumped determined? --- --- --- -_- - - - ---- - — Reason for pumping: - - Type of System: 0 Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy El Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the IIA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): 151ns-3113 Title 5 Official tnspeclion form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts -, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 186 Patriot Wad Property Address Hasz Realty Trust, Victor Hadawar Trustee Owner Owner's Name ~��~ information is required Centerville Ma 02632 6/27/2.018 - - r ---.--------�--� page. Cityrrown State Zip Cade Date of Inspection D. System Information (cons.) Approximate age of all components, date installed (if known)and source of information: Original system 1979 with 4 Infiltrators added 2-13-1997 _ Were sewage odors detected when arriving at the site? ❑ Yes 0 No Building Sewer(locate on site plan): 1 Depth below grade: feet Material of construction: ❑ cast iron ©40 PVC ❑ other(explain): w- -- - ---- - - Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joint were ok, no leaks, vented through the roof Septic Tank(locate on site plan): Depth below grade: .5 - -- feet, Material of construction: 9 concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal; list age: -- years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallons Sludge depth: 6" t5Uu•3113 Tills 5 Official,inspedron Forms Subsurface Soomee Dtaposat System•Page 9 of 17 Commonwealth of Massachusetts - c Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 186 Patriot Way Property Address Hasz Realty Trust, Victor Hadawar Trustee _ Owner Owners Name information is required for every Centerville Ma 02632 6/27/2018 —_..�... �.�.�..»_,.._,.. .k...-......w. .,.._..M..,_.w,. �_ page. Ctlyrrown State Zip Code Date of Inspection D. System Information (cont,) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 3" Scum thickness 3' ---- 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 10 How were dimensions determined? opened covers, took measurements ____ Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank should be pumped soon and again every 2 years for proper maintenance. water level was even with outlet, tank was not leaking and was structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: concrete ❑ metal ❑ fiberglass ❑ polyethylene []other(explain): Dimensions: - -- - Scum thickness --- - — ----- Distance from top of scum to top of outlet tee or baffle — --- - --- - Distance from bottom of scum to bottom of outlet tee or baffle ---- ------ ------------ Date of last pumping: Date 15im•3113 Title 5 OtflGat Inspection Form;suosurtaco sewage oisposot system•Pago io or 17 Commonwealth of Massachusetts �a = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 186 Patriot Way _ Property Address Hasz Realty Trust, Victor Hadawar Trustee Owner Owner's Name information is Centerville Ma 02632 6/27/2018 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: -�- - Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t&ns•31Q line 5 Official Inspection Form Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts { Title 5 Official Inspection Form ° Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 186 Patriot Way _ Property Address Hasz Realty Trust, Victor Hadawar Trustee Owner Owner's Name information is Centerville Ma 02632 6/27/2018 required for every .,_, „_,,.,�,_�,,, page. CitylTown state ' Zip Code Date of Inspection D. System Information (cone.) Distribution Box (if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0„ Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box was video inspected and found in good condition, no rot, water level was even with outlet inverts. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes [❑ No' Alarms in working order: ❑ Yes ❑ No` Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 5ns•3i1 3 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 12 of V Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 186 Patriot Way Property Address Hasz Realty Trust, Victor Hadawar Trustee. Owner Owner's Name information is Centerville Ma 02632 6/27/2018 required for every . -... -.-- ----- page. CitylTown State Zip Code Date of inspection D. System Information (cont.) Type: ® leaching pits number: 1x1000 Q leaching chambers number. 4 Infiltrators ❑ 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,): s.a.s. consists of a precast leach pit and 4 Infiltrators added 1997. Pit was found to have 3"standing water with a stain line 1' higher. Stone surrounding Infiltrators was probed and found dry with no sign of past saturation. Vegetation was normal. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration — - Depth-top of liquid to inlet invert -- Depth of solids layer Depth of scum layer Dimensionsof cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3113 Ufa 5 Ofhidal Mapection fon-Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 186 Patriot Warr Property Address Hasz Realty Trust, Victor Hadawar Trustee Owner Owner's Name information is required for every Centerville Ma 02632 6/27/2018 . .�....� page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions ------ Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc,); L•tSins 3ft3 Tale 5 Official Insoection Form:SUhsurfece Salvage OFsposal System•Pape 14 of 17 r Commonwealth of Massachusetts -r Title 5 Official Inspection Form --_ Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 186 Patriot Way Property Address Hasz Realty Trust, Victor Hadawar Trustee Owner owner's Name information is Centerville Ma 02632 6/27/2018 required for every -- - ------,--.----�--�. page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: (� hand-sketch in the area below ❑ drawing attached separately F" AZ ZS� f Al ar'6 01 30' / $� yz 1S" z bins•3/13 Title 5 Official Inspeclion Form Subsurface Sewage Disposai System•Pago 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments r 186 Patriot Way Property Address Hasz Realty Trust, Victor Hadawar Trustee Owner Owner's Name information is required for every Centerville Ma 02632 6/27/2018 -.. page. CityTTown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope El Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers- (attach documentation) (.I Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. Before filing this inspection Report, please see Report Completeness Checklist on next page. t5ins•W13 Tltfo 5 official inspection Form;SubaurfaceS"o Disposal System•Page to of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 186 Patriot Way_ Property Address Hasz Realty Trust, Victor Hadawar Trustee Owner Owner's Name � �� � information is required for every Centerville Ma 02632 6/27/2018 �._ page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B,C, D, or E checked Y. inspection Summary D (System Failure Criteria Applicable to All Systems)completed © System Information—Estimated depth to high groundwater © Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 15ins-3113 TWO 5 Official fnspodion Form Subsurface Sewago Disposal Systom•Pop 17 0117 TOWN OF BARNSTABLE LOCATION y 9,U Pw w as 7 tA,0-1 SEWAGE# VILLAGE_'-�W�`�"ya ("ten— ASSESSOR'S MAP & LOT C- INSTALLER'S NAME&PHONfi NO. SEPTIC TANK CAPACITY LEACHING FACELlTY: (type)" L7"-7t nS (size) 0 �1` �y K"2 NO.OF BEDROOMS J BUILDER OR OWNER :Z�7z PERMIT DATE: COMPLIANCE DATE: 7 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 - �; �3 3 � s ���� � o J No. � �-d Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIppYication for Migpogal *pgtem Congtruction Permit Application for a Permit to Construct( )Repair(4upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 1<3(p W1 OT'WA-Y 6CHM Owner's Name,Address and Tel.No. Assessor's Map/Parcel s D�\u 3 cO Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 1�5t� be--rs Gyp, W- Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 33a gallons per day. Calculated daily flow -3 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. i-Tr-C,7-0 L1 Description of Soil 1 � Nature of Repairs or Alterations(Answer when applicable) NrC1LZrato 25 wI"��'� ��{`t vf--\C)eV- A-w -(FT- DN St C1>=S Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been is Signed Date 7 Application Approved by Date -2 1-2 - P2 Application Disapproved for the following reasons Permit No. 9L Date Issued TOWN OF BAItNSTABLE LOCATION PW tV JrJ 7 tX10-j SEWAGE # - J/--' - VILLAG ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. 40 p SEPTIC TANK CAPACITY LEACHING FACILITY: (type) `�"�r L( r�Y��S (size) Y NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: v9 COMPLIANCE DATE: — l 1(77 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 I 0 V � � No. �`~ ,.._ �,.....�.'-�S_ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ZIpprication for Mgozar *p!gtetn Congtruction Permit Application for a Permit to Construct( )Repair('' )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. t'3(a S Y 1 OT w W�/ �h�i Owner's Name,Address and Tel.No. ` Assessor's Map/Parcel b c(' Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. ere,- 2d A c, Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures i Design Flow gallons per day. Calculated daily flow -u gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank SKr 5-,• s l D D0 4)� ti Type of S.A.S. Si.. LTr a T a Description of Soil C: <_Apko Nature of Repairs or Alterations(Answer when applicable) -T'N `ZrewTo2S wi-� 1141, ui—ocv- 4 g 0 4Fr O S i Date last inspected: Agreement: 1 The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been i 13 Signed Date_ d '� 7 Application Approved by Date . 1J --9 2 Application Disapproved for the following reasons Permit No:�,.,. 9 7--G_G7 Date sued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERT that the O - ' ewage Disposal System Constructed( ) Repaired ( )Upgraded Abandoned( )by cQ �► � �pc r� at ujvor�4 Cefk- (rr has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 92'4 Q dated f j - 9 7 . Installer Designer The issuance of this�ermit shall not beconstrued as a guarantee that the system will function as designed. Date CX. e `9 Inspector �� f Q----- ---- ---------- ——————— No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS 0i5po5ar *pgtem Congtruction Permit Permission is hereby granted to Construct( )Repair( grade( )Abandon( ` System located at I yT V--r'g=" and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. 14 /- Date: a �� R !�7 Approved by C/�l-t `lk � f 11 / E=t•,/� NOTICE: This form is to be used for the repair of failed septic systems only CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLAN I.a tr \p�✓` , hereby certify that the application for disposal works construction permit signed by me dated :2 concerning the property located at �(� P� � D �- ( C�``` T meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. SIGNED: DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. q:health folder:cent COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENviRoNMENTAL AFF DEPARTMENT OF =OSTONO NMENTAL } ( ' ONE WINTER STREET, MA 02108 (617 N ti WII.LIAM F.WELD F � /y TRUDY CORE Governor l 1" L 47& Secretary ARGEO PAUL CELLUCCI B. STRUHS 9 Lt. Governor �� �i ly Q� p� T Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION � b PART A CERTIFICATION Property Address: Address of Owner: yAv_� tAt s 7Zo1n.v 3& Date of Inspection: a\,o\c1-t (If different) Name of Inspector: Company Name, Address and Telephone Number: I' 14V�Ty_ ,L. xZ y �irr��pc�c� Ci 2 4�1 CERTIFICATION STATEMENT SOQS I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _ Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority ails ` Inspector's Signature Date: (5 `,O ct 1� The System Inspector shall submit a copy of this inspection report to the Approving Authority 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. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. 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, 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 conforming septic tank as approved by the Board of Health. (revised 11/03/95) V.. Pnou i on RPgtICA Pam-, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of°Ins edion n, B] SYSTEM CO D1 ONALLY PA�655E5`(continued) c.. c Sewage,t a kuu or breakout or high static water level observed in the distribution box is ue to broken or obstructed err- , ` pipe s')toi1 ue to ai� box. The system will pass in coon if(with approval o the roken, settled or uneven distribution Board of Health):+ .r � 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 bstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of He th 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 DETERMIN 5 THAT THE SYSTEM 15 NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAF AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of a surface ater Cesspool or privy is within 50 feet of a border' g vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEA H (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER HAT PROTECTs THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and it absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. _ The system has a septic tank d soil absorption system and is within a Zone I of a public water supply well. _ The system has a septic tan and soil absorption system and is within 50 feet of a private water supply well. _ The system has a septic to and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a w water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution fr that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. 3) OTHER (revised 11/03/95) 2 a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: \v(. 1�T¢Ao k Owner: \� Date of Inspection: D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined 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. Backup of sewage into facility or system component due to an 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. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 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: 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: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property ddress: Owner: i 1 Date of Inspection: dI1U1�� Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. LNone 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. 44As 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 condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. ./ The size and location of the Soil Absorption System on the site has been determined based on existing information or \\approximated by non-intrusive methods. /�The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Suit Urface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C _ SYSTEM INFORMATION Property Address: Owner: &I Date of Inspection: A OI cj'1 FLOW CONDITIONS RESIDENTIAL: Design flow:?x73Ogallons Number of bedrooms: Number of current residents: Garbage grinder(yes or no):_p30 Laundry connected to system (yes or no): 42 — Seasonal use (yes or no):_L.)4;p Water meter readings, if available: litp, . Last date of occupancy:.�i� - COMMERCIAUINDUSTRIAL: Type of establishment: Design flow:_gallons/day 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 a4 source o information: �kv4e- iyt1l System pumped as part of inspection: (yes or 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) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) (revised 11/03/95) $ Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: &c.-( Date of Inspection:a( %4cll SEPTIC TANK: (locate on site plan) Depth below grade:,ALGAft e- Material of construction: X concrete _metal _FRP —other(explain) Dimensions: Sludge depth:- Distance from top of sludge to bottom of outlet tee or baffle: 14' Tam_ Scum thickness:_ Distance from top of scum to top of outlet tee or baffle:_&CA TEr.. Distance from bottom of scum to bottom of outlet tee or baffle:_&.rdS 1i-gs, 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.), rn t_� L� t a� GREASE TRAP: fJO (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —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: 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 11/03/95) 6 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Addr s: (Q(v PA TQ1 f Owner: �� Date of Inspection: TIGHT OR HOLDING TANK:_ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP—other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:*S (locate on site plan) � IIDepth of liquid level above outlet invert: Comments: note if leve! and diSt{ibution nis q I, evidence of solids carryover, evidenA of leakage into or out of box, etc.) Eck -'•.o �+••-c� � � �S b,T��_�,�u �J �t ��ac�IC�Rnn-�9._-- o� o�� G�f�.k d PUMP CHAMBER: 100 (locate on site plan) Pumps in working order.(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection:-IA \\C,- SOIL ABSORPTION SYSTEM (SAS): S (locate on site plan, if possible; excav lion not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: LK4. leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs hydraulic failur lev of pondin condition pf veoeta�tio_n,et .) • g of- —1� — �1/I'1 CESSPOOLS: NO (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:� (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C P SYSTEM INFORMATION (continued) Property Address: Owner: , \ Date of Inspection:ai SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' I Cs rp DEPTH TO GROUNDWATER Depth to groundwater: t Zo feet t method of determination or approximation: (revised 11/03/95) 9