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HomeMy WebLinkAbout0499 PHINNEY'S LANE - Health (2) 499 PHINNEY'S LANE, CENTERVILLE A= 230101.004 " UPC 12543 No, 531OR HAVINGS, h+N t` Commonwealth of Massachusetts .: 1.� f Title 5 Official Inspection Form l MI Subsurface Sewage Disposal System Form -Not for,Voluntary Assessments + 499 Phinneys Ln Property Address Robert Silverberg Owner Owner's Name / information is required for every Centerville ✓ MA 02632 3-13-21 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. Inspector Information sa qa- Shawn Mcelroy Name of Inspector ' Upper Cape Septic'Services Company Name P.O. Box 73 Company Address East Falmouth MA 02536 City/Town State Zip Code 508-495-0905 S 13971 Telephone Number License Number B. Certification I certify that:) am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000);1 have personally inspected the sewage disposal system at theproperty address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of'on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes' ' .2.. ❑ Conditionally.Passes , 4 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 3-13-21 inspector's Signature l 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts j' Title 5 Official Inspection form hl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 499 Phinneys Ln r Property Address Robert Silverberg Owner Owner's Name information is required for every Centerville MA 02632 3-13-21 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6., 1) 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: System is in good working order with no sign of failure. 2) System Conditionally Passes: ❑ One or more system components as described in the "ConditionalPass,' 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 i Commonwealth of Massachusetts , iw Title 5 Official Inspection Form i-► Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 499 Phinneys Ln J Property Address Robert Silverberg Owner Owner's Name information is Centerville MA 02632 3-13-21 required for every •' page. City/Town , State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high staticwater 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 r❑ Y ❑N '❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑Y ❑'N El ND (Explain below): i In- ! ❑ 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 El ❑ ND (Explain below): ❑ obstruction is removed ❑Y ❑N ❑ ND (Explain below): 3) 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. a. 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: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 cam" Commonwealth of Massachusetts y Title 5 Official Inspection .Form ,& Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 499 Phinneys Ln Property Address Robert Silverberg Owner Owner's Name information is required for every Centerville MA 02632 3-13-21 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: - 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes , No ` ❑ ® Backup of sewage into facility orr 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form �► Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a , 499 Phinneys Ln Property Address Robert Silverberg Owner Owner's Name information is required for every Centerville MA 02632 3-13-21 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) - Yes No , 0 ® 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 Wday 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 water supply El ®, well. ' ❑ ` ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. t. _ t ❑ ` ®' —Any portion of a cesspool or`pdvy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is.equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design.flow of 2000 gpd- 10,000 gpd: ❑ ® 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. 5) 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 god. ' •.For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. 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 t5insp.doc•rev.7/26/2018. Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 < Commonwealth of Massachusetts - Title 5 Official Inspection Form Inl Subsurface Sewage Disposal System,Form -Not for Voluntary Assessments 499 Phinneys Ln Property Address Robert Silverberg Owner Owner's Name information is Centerville MA 02632 3-13-21 required for every ' page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) - - . •$ . ' . If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional,office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: 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 Iflows 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 I. available note as N/A ® ❑ + Was the facility or dwelling inspected for signs of sewage back up? e e •1 11 . . ® ❑ 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? ® Wasthe 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)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts r j� Title 5' Official Inspection Form r�l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y� Y_�-•Tyi�/ ` 499 Phinneys Ln Property Address Robert Silverberg Owner Owner's Name information is required for every Centerville MA 02632 3-13-21 page. City/Town State Zip Code Date of Inspection D. System Information , 1. Residential Flow Conditions: Number of bedrooms (design): N/A Number of bedrooms (actual): 3 DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): N/A Description: Number of current residents: 0 Does residence have a garbage grinder?, ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: 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: ! 2020 Date t5insp.doc•rev.7/26/2018- .. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 " ,� Commonwealth of Massachusetts 41 ,a Title 5 Official Inspection Form ,bi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 499 Phinneys Ln Property Address Robert Silverberg Owner Owner's Name information is required for every Centerville MA 02632 3-13-21 ' page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: ' Design flow(based on 310 CMR 15.203):- Cations per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? u ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): J t . 3. Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 c Commonwealth of Massachusetts f. Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments V 499 Phinneys Ln Property Address Robert Silverberg Owner Owner's Name information is required for every Centerville MA 02632 3-13-21 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: t ® 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) and a copy of latest inspection of the I/A system by system operator under contract ❑ -Tight tank.Attach a copy of the DEP approval. ❑ '' Other(describe): Approximate age of all components,.date installed (if known) and source of information: 1980's Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 18"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. t5insp.doc•rev,W2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form. 1 hl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 499 Phinneys Ln Property Address Robert Silverberg Owner Owner's Name information is Centerville MA 02632 3-13-21 . required for every . page. City/Town State Zip Code Date of Inspection D. System Information (cont.) `. 6. Septic Tank(locate on site plan): d Depth below grade: 12"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1, If tank is metal,.list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: 12" Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle' 16" How were dimensions determined? Tape 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 is in good condition with baffles installed and no sign of leakage. R t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 i Commonwealth of Massachusetts iw Title 5 Official, Inspection Form i 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 499 Phinneys Ln Property Address Robert Silverberg Owner Owner's Name information is required for every Centerville MA 02632 3-13-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet . Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): • Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): a 8. 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts I w, Title 5 Official Inspection Form ,iio Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 499 Phinneys Ln Property Address Robert Silverberg Owner Owner's Name information is required for every Centerville MA 02632 3-13-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) 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 9. 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.): Good condition with water at working level and no sign of back-up from pit. D-box had minor tree root instrusion. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 I Commonwealth of Massachusetts ;w. Title 5 Official Inspection Form ' N Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �1_,•�,; `J 499 Phinneys Ln Property Address Robert Silverberg Owner Owner's Name information is required for every Centerville MA 02632 3-13-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. 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. 11..Soil Absorption System (SAS) (locate on site plan, excavation not required): , If SAS not located, explain why: Type: ® leaching pits number: 1-1000 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 ! " Commonwealth of Massachusetts 3. Title 5 Official Inspection. Form ,ill Subsurface Sewage Disposal System Form -Not for Vol untary'Assessments 499 Phinneys Ln Property Address Robert Silverberg Owner Owner's Name information is required for every Centerville MA 02632 3-13-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit had a light stain line at 12" below inlet invert with a heavy dark stain line at 36" below inlet invert. 12. 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 i Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts fw Title 5 Official Inspection Form 14 hF Subsurface Sewage Disposal System Form -Not for Voluntary.Assessments 499 Phinneys Ln Property Address Robert Silverberg Owner Owner's Name information is Centerville MA 02632 3-13-21 required for every - page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13, 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.): f t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form t li'i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 499 Phinneys Ln Property Address Robert Silverberg Owner Owner's Name information is required for every Centerville MA 02632 3-13-21 page. City/Town - . State Zip Code Date of Inspection D. System Information (cont.) a 14. 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 14 1 76 r 6 ��r' &.3 e, Gj jy t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts fw Title 5 Official I nspection form i.l Subsurface Sewage Disposal System.Form -Not for Voluntary Assessments 499 Phinneys Ln Property Address Robert Silverberg Owner Owner's Name information is required for every Centerville MA 02632 3-13-21 ' page. City/Town State Zip Code Date of Inspection D. System Information (cont.) - 15. Site Exam: z ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells , Estimated depth to high ground water: 20' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checkedim date of design plan reviewed: pate ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database- explain: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at about 20'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts µ. Title 5 Official Inspection Form rol Subsurface Sewage Disposal'System Form -Not for Voluntary Assessments 499 Phinneys Ln Property Address Robert Silverberg Owner Owner's Name information is required for every Centerville MA 02632 3-13-21 page. City/Town ' State Zip Code Date of Inspection E. Report Completeness Checklist i Complete all applicable sections of this form inclusive of: 1 ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14:Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15:Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 (3z a,--fa COMMONWEALTH OF MASSACHUSETTS EXTJTIVE,QFFICE OF ENVIRONMENTAL AFFAIRS > DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART•A CERTIFICATION Z © � QO�., LOT Property Address: i Owner's Nam Y-194 Ld I/Ar 4 Owner's Address: S I�NJ LRrCE 'EDDate of Inspection: 1 - �y -na 2 8 2002Name of Inspector: (please print) l/a/id/ 19• )/�V io i OF BARNSTABLE Company Name; 3dkAl A . AA.47 g/yLelipgo ij��2�/c% ALTH DEPT. Mailing Address:.- • g2 klAl•AzuT SMr, f /41'44,f Telephone Number; S-o S -y12 -7-779 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 an e a d complete of the time of.the inspection.!The inspection was performed based on my training and experience in the prope r#'unction 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 " Needs Further Evaluation by the Local Approving Authority Fails 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. 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-I46!tOR'VOI UNTARYtASSESSN19NFS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(comt:inued) Property Address: 0 4 Owner: N o Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete`AH�f SeOAWI-D A. System Passes: S I have not found any information which indicates.that any of the failure criteria described in 310 CMR I5.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditional] Passes: y y 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 lank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank fail=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 breakout 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 inspwion 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 PARTk , CERTIFICATION(continued) Property Address: 5 � A/),1V Ze Owner: Al&,Pfl R 7"o W/V Date of Inspection: /-2•t/ - oa. 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: A ' ...st J it ., • - 3 Page 4 of 11 y. OFFICIAL INSPECTION FORM NO'T's. 'gR=VOLUNTARY ASSESSMENTS ` SUBSURFACE SEWAGE DISPOSAL'SYSTEM;1NSPEM— 0NX0RN,. = A ' PART: ' s: CERTIFICATION`(caatmued): Property Address: /I S Nl-- a ' ��wi�ll2ii 2� - Owner• Date of Inspection: 1-a5L Z D. System Failure Criteria applicable to all systems:. . You must indicate"yes"or"no"to each of the following fof all inspections Yes,, No �._ Backup cku of sewage e into facility system em component du to`over1 oaded r clogged SAS or cessP,00l . t/ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded,or clogged SAS or cesspool P1 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''/I day flow !L' 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. . . t/ 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. v Any portion of a cesspool or privy is less than 100 feet but greater than"50'feet'from aprivate'water supply well with no acceptable water quality analysis. [This system passes if the-wM 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 failmm criteria are triggered.A copy of the analysis must be attached to this forma Alo (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 tocon-ect the failure. _ r , 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 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�VOLUNTARYASSESSMENTS SUBSURFACE SEWAGE DISPOSAL:SYSTEM INSPECTION FORM PART B t ,:CHECKLIST Property Address: 73 ? I�AMIX! C 1"g C�ERv�i'11 Owner: " o �.t1 Date of Inspection: Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No - Pumping informatiori'was provided by the,owrier,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? 1� Have large volumes of water been introduced to the system recently or as part of this inspection? I/ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) V _ 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? ` V, Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the b_affles or tees,material of construction,dimensions;depth of liquid,depth of sludge and depth of scum? V _ 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 jSAS)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 6of11 r x 'i r OFFICIAL INSPECTION.FORM NOT FOR'Vi)iAq�ASSESSMEA'TS. SUBSURFACE SEWAGE DISPOSAL.'SYSTEM.'INSPECTION FORM,:"' PART C SYSTEM INFORMATION Property Address: X'9q 1014°N11«yt .ARA/A' Date of Inspection: 1.2 FLOW CONDITIONS _. RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms DESIGN flow based on 310 CMR 15.203(for example:"110'gpd)(#°of bedrooms):' Number of current residents: _ 2 Does residence have a garbage grinder(yes or no): Rlo Is laundry on a separate sewage system(yes or no): tV0 [if yes separate inspection required],, rT y. Laundry system inspected(yes or no):_ _ Seasonal use: (yes or no): o Water meter readings,if available(last 2 years usage(gpd)):L20va Sump Pump(yes or no): AID F; S.f? (: • �. :r_ ,., . ':.1 Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): pd 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: r. Last date of occupancy/user _.... _. OTHER(describe): 0 ,,: GENERAL.INFORMATION , Pumping Records ,: .r.••u, .,. Source of information: .5zive ' Was system pumped as part of the inspection(yes or no): Nd If yes,volume pumped:_gallons--'How was quantity pumped determined? Reason for pumping: TYrE 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.Attkka 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: /G _ _ . Were sewage odors detected when arriving at the site(yes or no): 6 Page 7 of I I G 'OFFICIAL INSPECTION FORM NOT.FORsVOLUNTARY ASSESSMENTS " `SUBSURFACE SEWAGE DISPOSAIAYSTEM INSPECTION FORM ':PART C r`SYSTEM INFORMATION(coritinfied) Property Address: <n/ilBBv le Owner:j3kA101-& T�o,� Date of Inspection: /"a�—O.Z _ .. _..a__ t..ucs. xc BUILDING SEWER(locate on site plantt'j 1,'r V ,. <N1 era Depth below grade: 2 rias9C: Materials of constivction:._cast iron` 40 P,VC "��-'other xplain):,, � _ :. . ... Distance from.private water.supply well or sin line:: _ _ �,w y. •_ „_•,__ ,, •� Comments(on condition of joints,venting,evidence of leakage,etc.): _ till? "1 s'l+..}1:�'•+'`a.:l rn%p. SEPTIC TANK:—(locate on site plan) ..70 1-,.1 Depth below grade: Material of construction:..:. concrete .:metal_fiberglass.—polyethylene.,,.ro ' other(explain) - � If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of , certificate) j Dimensions: $ X '1 ,.� _ t't:�14? ..t :�#,>i1 ,. �..t,�•,t; Ic,.;i�r ,1.:�ace- p_ .......liCl t";J�,Ti.+P11:s 7,"I'l a Sludge depth: r Distance from top of sludge to bottom of outlet tee or baffle Scum thickness:".:3� ,.; ..� . : , .,.,�,.+ =` ;ar, r:t.. .3.: . .y,:.., •�,�, ,r u r t € r3 . •. n'2 _ ,r>._ .ci� - �r •f t•. .�e "r ^, Distance from top of scum to top of outlet tee or baffle: o ; + `��r, _ �x�-: <•�. .,Distance from bottom of scum to bottom of utlet tee or.baffle:. /3,�.,: ..How were.dimensions determined: ._ Yu: r. A .`/Y/��eSta'r.i•.� S � Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet vert evidence of.leakage,etc.): pUc h.lc T49k 4 Co�cre�i kt/���„���,p : E �F�� � 1�0.[5 n t Ht� •dN r,�C.�a� �7r3 L11�pr � •• . .. . ..,,. 'F.:r iG„WY, .^.?:1'•:�^..a:)'� {.{ C7�rY9I�i ri t YJ GREASE TRAP:_(locate oa siteplan). ..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: I 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.). Page 8of11 OFFICIAL'INSPECTION.FORM`—NOT VRVYQLUNTARY ASSESSMENTS tz i ft l SUBSURFACE SEWAGE DISPQSAL.SYSTEM INSPECTION;FORM. :PART;C SYSTEM INFORMATION:(continued) Property Address• " Owner: Date of Inspection: . S p Y zi0 2 . _....w_. ... _ TIG pumped at or HOLDING TANK: (tank must be pu at time of in'speic an site plan) .. Depth below grade: , Material of construction: concrete metal fiberglass ""=polyethylene, other(explam): 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: '4"" (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0�' ;} ° :•r7 ; ° t� 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.): ,. .-.�k.r �•a. t ',l:°i .. :: °.`t�, .....4t-., ...-F*� .s _ .,�. �. U :.;w°z .-.,,. !; .x, ,, iy .. ..'i .., t .r PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): a. Comments(note condition of pump chamber,condition of pumps and.appurtenances,etc).. .:. k •, 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: y 9 9 6r, Al Owner: Jiw 'it io in Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type ✓leaching pits,number: 1 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.): 6� 1��.H�G1 �.o�t/ G�' .6�N•, a�' �if. - /�oD aa. /, �e���,�� f w�f/a„Q��sc.F CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 �, Page 10 of 11 OFFICIAL INSPECTION FORM-NO'�FOR VOLUNT)MY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SY91E1h INSPECTION FORM PART . SYSTEM INFORMATION(continued) Property Address: 99 /0,4, yyQ e� C0hh�v,111,e Owner: TehhZ{vr rOca�h Date of Inspection: 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 y: rr 3` „ 3 .n 7o tovlr .�G 6" 7$ q 10• Page 11'of`1 ;.OFFICIAL INSPECTION,FORM,-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM z ' •� k PARS'C £,} "# K SYSTEM INFORMATION(continued`) PropertyAddress: y T oih c Date oflnspection:3 SITE EXAM kGh4( Slope, . Surface water z'•Check cellar Shallow wells Estimated depth to ground water 14 9 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 ` { V Observed site(abutting property/observation.hole within 150 feet of SAS) Checked with local Board ofHealth-explain. ". 5 • r Checked with local excavators,installers (attach documentation) Accessed USGS database explain ., .`:You must describe how y ou established the high ground water elevation: v�af`r 1�vel ®f �JYe` a�usfrm( rs. t35f. ,s �; . wA G0 h %g t'ro� i i l i . r <. . 11 a COMMONWEALTH OF MASSACHUSETTS �y EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS 2 DEPARTMEIT OF ENVIRONMENTAL PROTEC ON.E WINTER STREET. BOSTON. MA 02108 61 i•292.5;00 RECEIVED MAR 2 7 1Ylt`l'1DY Govemo:. WILLIA F.WELD OFBARNSTABLE Se {Off, HFALTHDL�AVID B. '� ARGEO PAUL CELLUCCI HS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM C i toner PART A 6'S CERTIFICATION Property Address: / ih h�r ti t Gfh/lrvd/e Address of Owner: y�3 �l- /h h.F Date of Inspection: (If different) Name of inspector: , 04,,7 9,_gai4l I am a DEP approved system inspect}r pursipant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: h A�t �IWC A-Ao S ✓✓/ Mailing Address: Al"'I" s J Telephone Number: — 1 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: n.4, a Date: �6— �'8 i f this inspection report to the Approving Authority within thirty (30) days of completing this The System Inspector shal subm t a copy o s pe p PP g 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. 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 conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web: httpJtwww.magnet.state.me.usldep Printed on Recyoed Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: i,6 1✓Q'11 .fu 17,,`Ie� Date of Inspection:-a�7' ,3-,/G-- 98 BJ SYSTEM CONDITIONALLY PASSES(continued) YT' 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). Describe observations: 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 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 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 APPROPRIATE) 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 I 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 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A /' // CERTIFICATION (continued) Property Address: 7 9? A,m hQ s Owner: Ge�I^G e T4Y-1� Date of Inspection: 16 9,Q D) SYSTEM FAILS: C� You must indicate either "Yes" or "No" as to each of the following: 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. 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 chwed 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 112 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 wamr 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 sup*well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for cohiorm 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 significarx 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 fl 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. I (revised 04/25/97) page 3 of 10 a 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: -e Owner: &evApe fy 77'je Date of Inspection: Check if the following have been done: You must indicate either "Yes" or"No" as to each of the following: Yes No ✓ _ 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. 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 v,,as inspected for signs of breakout. �d-1,4f _ All system components, e*e6dirrg 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: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)) (revised O4/25/97) Page 4 of 10 i } SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: ivr h{�� XaH..e �'.yrYv/���� A114- Owner: GPOtC�L .rum Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: 110 g,p•d./bedroom for S.A.S. Number of bedrooms: Number of current residents: Garbage girder (yes or no): Al,, Laundry connected to system (yes or no):4rs Seasonal use ryes or no): A/0 _ Water meter readings, if available (last two (2) year usage (gpd): A/7 Sump Pump (yes or no):­Z& Last date of occupancy: /6-y7 COMMERCIAL/INDUSTRIAL: 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 o:cupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)-5 If yes, volume pumped: 1670a gallon--s Reason for pumping mlrw.1i . o fe"*"C o 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) I/A Technology etc. Copy of up to date contracts' Other APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no),I (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: g9 �n i h N P�S )ti'N-e-� Owner: (Te0 r�j.� .ry /f1� Date of Inspection: / a 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 lint: Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:_ (locate on site plan) Depth below grade: 41 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: 3c `� 8" l� S Sludge depth: 8" Distance from top of sludge to bottom of outlet tee or baffle: /6" Scum thickness: 7'1 Distance from top of scum to top of outlet tee or baffle: .d Distance from bottom of scum to bottom of outlet tee or baffle: 9 v How dimensions were determined: RNl1" gt iNQasav� rT�h 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.) N A, /< o� /' Hk s p(/4 mhf P-e Q Cnvr v 1 ULt �� y� GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: _concrete _metal_Fiberglass _Polyethylene —other(explain) Dimensions: Scum thickness: .Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 04/25/97) Fag• 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: �OfGf A l� {.g� Owner: OA• ' ��/7-e/ / Date of Inspection: TIGHT OR HOLDING TANK: OP Rank 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/dav 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:_ (locate on site plan) Depth of liquid level above outlet invert: o � Comments: (note if level and distribution is equal, evidence/of solids carryover, evidpricee of leakage into or out of box, etc.) XA 7N4C/jON/.7g .pGf/j7�s�yryl e PUMP CHAMBER: lVd (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.) r (revised 04/25/97) Page 7 of 10 , Y 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1' ��jia �<t g9 �ihl�s N Owner: Date of Inspection: eor�e A. 7�;—/, , SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined,to be present, explain: Type: leaching pits, number: / 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 pondin condition of egetation etc.) D.r/� / /�o.N,� Lev c/ a 7� /3oa o f /OOb -{yid +a c id y i4 SR s 710tc o'*'b CESSPOOLS: _ (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 04/25/97) Page 8 of 10 V SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: h AiSys ilf H� ep�j� /1 Owner: �QO�j� 7``! ��e / �v/ �/ Date of Inspectio // 3- 9q SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public wafter supply comes into house) ,r 17 p y i Xq 11r i z 3 y31 I _ I (rrvirad 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: Depth to Groundwater 17.9 Feet + Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record il' Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records _ Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. Must be completed) lit e'v L ice,. npl { G S k a45 9-'vti�,� G� 1 5­2 `I s l .7 GSI� 14 � (revised 04/25/97) Page 10 of 10 T4_ Op:Bj!gtl TAB ,E 9 Lea �g�„�jl1SGE�(y�'O11il�Nft, P.�f�$O�R`� I�1�► L� ,� mv ea�tr' Ttdd ►g�,,,-1 ..� � �c19i mat 0���.Z8�10$ ��WC�81t�5L'X�SI.: •� ': '{Nett��• +Of�C8C5iA�;� .( Fr V,: 3 �_ - o ' a �l - a9'y��