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HomeMy WebLinkAbout0422 PINE STREET (HY - Health (2) 422 Pine Street Centerville P A = 228 026 R No. 4210 1/3 ORA m undwd 10% P. 1 Communication Result Report ( Oct. 1. 2018 11 :48AM ) 2) Date/Time: Oct. 1. 2018 11 :47AM File Page No. Mode Destination Pg (s) Result Not Sent ---------------------------------------------------------------------------------------------------- 1405 Memory TX 915087717622 P. 4 OK ---------------------------------------------------------------------------------------------------- Reason for error E. 1) Hang up or line fail E. 2) Busy E. 3) No answer E. 4) No facsimile connection E. 5) Exceeded max. E—mail size E. 6) Destination does not support IP—Fax TOWN OF BAMSTABLIE Heahh Diddam—zoo Mam sheer- MA 02601 FAX DaW 0� . �� - 1lambaofpsga9iorlvditigcweiatxt�' .TO/:•' FROM: R.OhMi—% _ P6cme: J PL�e: 50&862-4644 Fsxpbm=c 2F-77!-74.2-1 P�cphuna '508-790.6304 H�4ARSS: ❑II*8..t ❑Por yunr ❑HgAYAW ❑Preue rnmmmt �ePieN • Commonwealth of Massachusetts aW Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments \,. 422 Pine Street, Centerville, Ma. Property Address Cynthia Hennessey Owner Owner's Name information is 422 Pine Street, Centerville, Ma. 02632 August 16, 2013 required for every 9 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. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Dan A. Speakman Rcz use the return Name of Inspector key. Company Name 15 Speak Way Company Address Harwich Ma 02645 City/Town State Zip Code 508-432-5565 SI 637 Telephone Number License Number B. Certification ua aa ni 1 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 c ``- 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 d Title 5610 CMR 15.000). The system: LLJ E—!'asses ❑ Conditionally Passes ❑ Fails f.,r�G ❑ Needs Further Evaluation by the Local Approving Authority 4 C- e -= ' August 25, 2013 1 I spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(BoS.d of Health or DEP)within 30 days of completing this inspection. If the system is a shared sV tem�d°i 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. /I 15ins•3/13 Title 5 OfficiVInspectiFSubsurface Sewage Disposal stem•Page 1 of 17 I it Commonwealth of Massachusetts Title 5 Official Inspection Form != — Subsurface Sewage Disposal System Form -Not for Voluntary Assessments `' — 422 Pine Street, Centerville, Ma. Property Address Cynthia Hennessey Owner Owner's Name information is required for every 422 Pine Street, Centerville, Ma. 02632 August 16, 2013 page. CitylTown 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: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 C.MR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: A ❑ 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): 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts U, Title 5 Official Inspection Form :l Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 422 Pine Street, Centerville, Ma. Property Address Cynthia Hennessey Owner Owner's Name information is required for every 422 Pine Street, Centerville, Ma. 02632 August 16, 2013 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) A) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): �V - ❑ 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: A/ ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 422 Pine Street, Centerville, Ma. Property Address Cynthia Hennessey Owner Owner's Name information is g required for every 422 Pine Street, Centerville, Ma. 02632 August 16, 2013 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) w 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 El Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ En"', Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Er,*" 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 Y day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts is= - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 422 Pine Street, Centerville, Ma. Property Address Cynthia Hennessey Owner Owner's Name information is 422 Pine Street, Centerville, Ma. 02632 August 16, 2013 required for every g page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ �/ 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. ❑ 21-- Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ 1�r- Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ❑� Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ❑/ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ❑/ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large sys m the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. #J For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (interim Wellhead Protection Area-IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5'ns•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 422 Pine Street, Centerville, Ma. Property Address Cynthia Hennessey Owner Owner's Name information is 422 Pine Street, Centerville, Ma. 02632 August 16, 2013 required for every g 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 ❑ [2"'� 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? 2__�❑ 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) I� ❑ Was the facility or dwelling inspected for signs of sewage back up? f� ❑ Was the site inspected for signs of break out? L� ❑ Were all system components, excluding the SAS, located on site? [2* ❑ 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: E� �❑ 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): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): U t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 422 Pine Street, Centerville, Ma. Property Address Cynthia Hennessey Owner Owner's Name information is required for every 422 Pine Street, Centerville, Ma. 02632 August 16, 2013 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes [-No Is laundry on a separate sewage system? (Include laundry.system inspection ❑ Yes E 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: -7, WD Sump pump? ❑ Yes 3­(Jo Last date of occupancy: P?Z1YS4La17' Date Commercial/Industrial Flow Conditions: -J Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 422 Pine Street, Centerville, Ma. Property Address Cynthia Hennessey Owner Owner's Name information is 9 required for every 422 Pine Street, Centerville, Ma. 02632 August 16, 2013 page. Cityrrown State Zip Code. Date of Inspection D. System Information (cont.) ^)tO 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 [-1lo If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: L� 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): t5ins•3/13 Title 5 Official Inspection 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 422 Pine Street, Centerville, Ma. Property Address Cynthia Hennessey Owner Owner's Name information is required for every 422 Pine Street, Centerville Ma. 02632 August 16, 2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: / 9CZ Were sewage odors detected when arriving at the site? ❑ Yes Et-*No Building Sewer(locate on site plan): Depth below grade: coT 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.): Septic Tank(locate on site plan): Depth below grade: feet Material of construction: oncrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) d If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: :50 ® g*°QC" Gw � Sludge depth: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 422 Pine Street, Centerville, Ma. Property Address Cynthia Hennessey Owner Owner's Name information is required for every 422 Pine Street Centerville, Ma. 02632 August 16, 2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 2�~ 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 JZ ' � How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Sul Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments <„ 422 Pine Street, Centerville, Ma. Property Address Cynthia Hennessey Owner Owner's Name information is required for every 422 Pine Street, Centerville, Ma. 02632 August 16, 2013 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) .0 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): �✓G� Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last.pumping: Date Comments (condition of alarm and float switches, etc.): `Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form �T -- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 422 Pine Street, Centerville, Ma. Property Address Cynthia Hennessey Owner Owner's Name information is required for every 422 Pine Street, Centerville, Ma. 02632 August 16, 2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): . Depth of liquid level above outlet invert C�:) Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): /L) l/off 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: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts a W Title 5 Official Inspection Form im Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 422 Pine Street, Centerville, Ma. Property Address Cynthia Hennessey Owner Owner's Name information is required for every 422 Pine Street, Centerville, Ma. 02632 August 16, 2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: 0� 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.): (S) /' �-ic.T-,.2 Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): -L) 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 ❑ No t51ns•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Q-2 _ -- v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 422 Pine Street, Centerville, Ma. Property Address Cynthia Hennessey Owner Owner's Name information is 422 Pine Street, Centerville, Ma. 02632 August 16, 2013 required for every g page. City/Town State Zip Code Date of Inspection D. System Information (cont.) a., Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): A-1 . Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form =' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 422 Pine Street, Centerville, Ma. Property Address Cynthia Hennessey Owner Owner's Name information is required for every 422 Pine Street, Centerville, Ma. 02632 August 16, 2013 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 2 3a.5• y��' N 382 ' sq o 2 a t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 v Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 422 Pine Street, Centerville, Ma. Property Address Cynthia Hennessey Owner Owner's Name information is required for every 422 Pine Street, Centerville, Ma. 02632 August 16 2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form =� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments N 422 Pine Street, Centerville, Ma. Property Address Cynthia Hennessey Owner Owner's Name information is 422 Pine Street, Centerville, Ma. 02632 August 16, 2013 required for every g page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist g-1 spection Summary: A, B, C, D, or E checked Inspection Summary D (System Failure Criteria Applicable to All Systems) completed stem Information — Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 �.` Permit Number: Date: Co-pleted by: HIGH GROUND-WATER LEVEL COMPUTATION Site Location: L Lot No. :Owner: Cl✓�Q� - Address: Contractor:— Address:_ Notes: . STEP 1 Measure depth to water'table 1 J to nearest VI i 0 ft. .................... Date month/day/Year STEP 2 Using Water-Level Range Zone and.1ndex Weli'Map locate site zhd determine: O^ . Appropriate index well.........................•. ,d�/ U• O Water-level range zone ............... - STEP 3 Using monthly repo rt."Current Water Resources Conditions" determine current depth to water level forindex well .......::............... .. �/ J month/year STEP q Using ,Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index.well (STEP 3), 'and water-level zone (STEP 2B) 777 determine waterdevel . .................................... 'STEP 5 . .Estimate depth to high'water by subtracting the water- .1eve1 adjustment (STEP 4) I. from'measured depth to water level at site (STEP 1)�.:.................. Figure 13.—Reproducible computaiiori iorm. �. r {t=lf�r ,............,�� ..m�.�.•-�.�..w1.,.N�......... ......�.....�...._•.�-..�. ...-.,..�.-.— � .... ..�...........a...... ;� .....n.tlLJ.e_M+.w.a /gyp/'.� !l� tee`.e'.....�.�. G S- i ., t 9 I �l Permit Number: Date: Completed by: HIGH GROUND-WATER LEVEL COMPUTATION Site Location: L r? c��` ?L C /'�`f�P Lot No. Owner. C� Q'll .Address: Contractor: DJ�j`r��/? � �(�� �• Address:_ Notes STEP 1 Measure depth to water table ft to nearest 1%10 . .................. .............................................................. .Date �r monh/day/year i STEP 2 Using Water Level Range Zone _ and.1ndex Well'Map locate site aid determine: OAppropriate index well....... Water-level range zone ......... STEP 3 Using monthly report,"Current Water Resources Conditions" determine current depth to © �� i water level for index well .......::.................. / J� month/year 1I STEP 4 Using ,Table of Water-level Adjustments for index well (STEP 2A), current depth to Water level for index.well (STEP 3)., i 'and water-level zone (STEP 28) determine water-level adjustment ................. q�j STEP b . Estimate depth to high water by subtracting the water- level adjustment (STEP 4) irom'measured'de'pth to water level at site (STEP 1) .:................ / 7e Figure 13.--Reprcducible computatiori jorm. 4� 1300 F i S23 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PR.OT .C-TIQ _._ RECEIVED • S E P - 8 2003 TOWN OF BARNSTABLE .I HEALTH DEPT. (( TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: Owner's Name Owner's Address: MAP Date of Inspection: 'S i PARCEL ` �3 Z. Name of Inspector plea e p int) 10 I`'r f 4-0T Company Name. � . Mailing Address:. c� 41 A 0 i�yr Telephone.Number: �. CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector.pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: /Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: The system inspector shall sub '-a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that ° time. This inspection does not address how the system will.perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I I Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. S stem Passes: I have not found any information which indicates that any of the failure criteria described to 3 10 CMR 15303 or in 3-10 CMR-15.304-exist.-Any-failure-criteria not evaluated are r d cated below! Comments: B. System Conditionally Passes: One or mores stem components as described in the"Conditional Pass"section need to be replaced Y r r ed or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health;will pass. Answer yes,no or not determined(Y,N;ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as'approved by the Board of Health. *A metal septic tank will pass inspection.if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20`years old is available. ND explain: Observation�of sewage backup or-b-reak-ouror 11iigh-static1water-levei in the distribution box due to broken or obstructed.p ipe(s)or.due to a broken;settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required.pumping more than'4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health):. broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of]'1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART 'A CERTIFICATION(continued) Property Address: 0 ` Owner. Date of Inspection ASS U. 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. Syste -4ili pass.unless Board of H:e'elth determines in accordance:with 310%h'iR 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 l 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 'bacieria'and-voiatiie organic compounds indicates that the well is free from pbiluti'on frbm that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A•copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: Date of Inspection: as,80L13 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes Nq Backup of sewage into facility or system componentdue 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 _ V Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped . Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface / water supply. Any portion of a cesspool or privy is within a Zone 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. [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.] (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct'the failure. E. Large Systems: To be considered a large system:the system must serve a facility with a'design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no 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—I WPA)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 H OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM d PART B� , .'; CHECKLIST Property Address: ~ Owner Date of Inspection: Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes, o Pumping information was provided by the owner, occupant,or.Board of Health Were.any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period ? — V 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) v _ Was the facility.or dwelling inspected for signs of sewage back up Was the site inspected for signs of breakout? Were all system components,excluding the SAS, located on site.? Were the septic tank manholes uncovered,.opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction, dimensions,depth of liquid, depth of sludge and depth of scum? Was.the facility owner(and occupants.if.different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System(SAS)'on the site has been determined based on: Yes no Existing information. For example,a plan.at the Board of Health. _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 Page of 11 OFFICIAL INSPECTION-FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE-DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: " Date of Inspection: FLOW CONDITIONS RESIDENTIAL(/ Number of bedrooms(design): . Number of bedrooms(actual): DESIGN flow based on 31 O.CMR 15.203 (for example: 11:0 gpd x 4 of bedrooms): 7 y' Number of current residents: Does residence.have:a garbage grinder(yes or no).: Is laundry on a separate sewage system (yes or no : [if yes separate inspection required] Laundry system inspected(yes or n2WtV Seasonal use: (yes or no.):.,/}- Water meter readings, ifl6vaiable(last 2 years usage(gpd)):D/ J�� d �Z'13 j©©O Sump pump(yes or no . ,, ��` ,,,, ,,� Last date of occupa y: � �ea/� �ief ��c fJ� �12��/ t/1w COMMERCIAL/INDUSTRIA/0,1�� Type of establishment:. Design flow{based on 310 CMR.15.203): gpd Basis of design-flow(seats/persons/sgft,etc.): . Grease trap present(yes or no): Industrial waste bolding tank present(yes or no):— Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system.pumped as part'ofthe inspection(yes r%no - If yes, volume pumped:.-_,._,. gallons--.How.was quantity pumpedadetermined? _ Reason'for pumping: . TY OF SYSTEM Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool Privy —Shared system.(yes or no)(if yes, attach previous inspection records,if any) Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank —Attach a copy'of the DEP,approval _Other`(describe): Approximate age of all mponents, date installed(if know )and sou ce of V IV Were sewage odors'detected when arriving.at the site(yes or no): 6 I Page 7 of 11 _,OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner. Date of Inspection: Q S BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron _40 PVC_other(explain),.. _ Distance from,private water supply well or suction liner .Comments(on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK: locate on s't plan) Depth below grade: x7& Material of construction: kL oncrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) _ Dimensions: /01 �J X 6 Sludge depth: 7,7 Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:/ Distance from top of scum to top of outlet tee or baffle: >i Distance from bottom of scum to bottom 9f outlet tee or baffle' /,3 How were dimensions determined: yip n p1� Comments(on pumping recommendations, i let and outlet tee or baffle condition, structural integrity, liquid levels elated to outlet invert,ev. nce of leakage etc.): r / 0 GREASE TRA, (locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 7 Page 8 of 1 I OFFICIAL:INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: c w Owner• Date of Inspection: T 0ex).13 TIGHT or HOLDING TANK:21}-(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: V' Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions' Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of fast pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX:�(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert�ution /<�Comments(note if box is level and distroutlets equal, any evidence of solids carryover,any evidence of age into or ou of box etc,): PUMP CHAMBE IV (locate on site plan) Pum s in working order p b (yes or no):: Alarms in working order(yes or no):._� Comments(note condition of pump chamber,condition of pumps anfdappurtenances,etc.): " 8 Page 9 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: joy A Owner: 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 liing chambers,number: %. eaching 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, et . CESSPOOL`S-(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 ground,,vater inflov (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=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ��1d11X Owner. 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. o 0 0 10 Page I I of I l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: popd Owner: Date of Inspection: 144tu 47 0- SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water Z j feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators; installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: 11 BORTOLOTTI CONSTRUCTION,IN 765 WAKEBY ROAD,MARSTONS MILLS, 648 `►! 508-771-9399 508428-8926 FAX: 508428-9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC 11� PART A CERTIFICATION Property Address: d? Date of Inspection: 7 h Inspector's N e: Owner's Name and Address: - /�1 O xo CERTIFICATION STATEMENT: I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of inspection. The inspection was per- formed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The System: Ni �/ Passes 1 Conditionally Passes Needs Further Evaluation By the Local Aproving Authority Fails Inspector's Signature: Date: �� The System Inspector shall submit a opy of this inspection report to the Approving authority within thir- ty(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: A)SYS'I M PASSES: �1 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 comple- tion of the replacement or repair,passes inspection. Indicate yes,nor,or not determined(Y,N,OR ND). Describe basis of determination in all instances. If "not determined",explain why not. a 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 sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup 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): _{ ti t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) 'rA , q, - Broken pipe(s)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 pipes)are replaced Obstruction,is removed _ a 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 FUNCTION- ING IN;A'MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: -`' - W The,system has';aseptic tank and soil 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 and soil absorption system and is with a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. The system has a septic tank and soil absorption system and 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 the.facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. 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. Discharge or ponding of efluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool.' Static liqurd'level in the distribution box above outlet invert'due to an overloaded or clog- ged SAS o cesspool. �'... Liquid depih 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 -2- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) `I 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 IS 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 FAE S: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 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 s! conditions exist: The system is within 400 Feet of a surface drinking water�supply 'The system is within,20.0 Feet.of.a tributary to'a surface drinking water supply The system is located in a nitrogen sensitive area Interim Wellhead Protection Area (IWPA)or a mapped Zone 11 of a public water supply well... 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 CNN 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: ✓Pumping information was requested of the owner,occupant,and Board of Health. ✓None of the system components have been pumped for atleast 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. 5�ML-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. system does not receive non-sanitary or industrial waste flow. i/The site was inspected for signs of breakout. ✓All system components,excluding the.Soil Absorption.System, have been located on site. The septic tank manholes were uncovered,opened,and the interior of the septic tank was in- spected for condition of baffles or tees,material of construction,dimensions,depth of liquid, 'E �4:Meth of sludge,depth of scum. size and location of the Soil Absorption System on the site has been determined based on , existing information or approximated by non-intrusive methods. -3- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . ., . . CHECKLIST(continued) :4 te facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS RESIDE Design Flow: Ions Number of Bedrooms: Number of Current Residents:_,_ Garbage Grinder: Laundry Connected To System: Seasonal Use: dr) Water Meter Rea gslable: Last Date of Occupancy: CO MF.R AIAND 1S IAi tiQ - Type of Establishment: Design Flow: 1;allons/day;FGrease.Trap Present: (yes or no) Industrial Waste Holding Tank Present: ' Non-Sanitary Waste Discharged To The Title V System: - - Water Meter Readings,If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENE:%L LNFORMATION 'x PUMPING RECORDS and source of information:ze4waa System Pumped as part of inspection: if-yes,volume pumped: RAons Reason for pumping: TYP!�W SYSTEM: ✓Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records, if any) Other(explain): ROaQMATE AGE of all components,da a installed(" own)and urce of.information: 'SeWfige odors detected w—lien arriving-at the site: -4- t Ti •C:.. 'V 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: Depth below grade: Material of Construction:_zconcrete metal FRP_Other (explain) b,.a Dimisions:JO.S'X eu 'X S Sludge Depth: Scum Thickness: Distance from top of sludge to bottom of outlet tee or baffle: 36 ' 777- Distance from bottom of scum to bottom of outlet tee or baffle:_ /i ° Comments: (recommendation for pumping;condition of inlet and outlet tees or baffles,depth of liquid 'G level in-relation to outlet invert,structural integrity evidenceA leakage,etc.) IlLaal q y; GREASE TRAP: 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: _Comments: (recommendation for pumping,-condition of inlet and.outlet tees or baffles,depth of liquid; _level in relation to outlet invert,stiuctural integrity,evidence of leakage,etc':) .. TIGHT OR HOLDING TANK:No 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: Depth of liquid level above outlet invert: aN?7." Pn Comments: (note if l el and distribution is eGual,evide a of solids carryover,evidence pf leakage into 0 out of box,et j0'a LJ l.YA PUMP CHAMBER: 1 Pump is in working order: Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) -S- ' .�a < 1 wy{ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) SOIL ABSORPTION SYSTEM(SAS): ✓ b (Locate on site plan, if possible;excavation not required,but may be approximated by non-intrusive ' methods) If not determined to be present,explain: Leaching pits,number: Leaching chambers, number: Leaching galleries,number: Leaching trenches, number, length: ` Leaching fields, number,dimensions: �`'t Overflow cesspool, number: Comment (note condition of so' signs pf hydrauli failure level of ponding,condition of vegetation, ' etc.) CESSPOOLS: A)b ' j 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 soilk, signs of hydraulic failure, level of pending,condition of vegetation, etc.) PRIVY: Nl) Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) • - .. fir; T�kt -6- f, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. s« moyg .. �) V 0 DEPTH TO GROUNDWATER: Depth to groundwater: S Feet _ Method of Determination or A pro 'mation: - ,- h V as 1`v TOWN OF BARNSTABLE LOCATION .L 0�� SEWAGE # V :LAGER ale,&a ASSESSO MAP & LOT.29'.1),--2( ZKSP.&—cr Q:sNAME&PHONE N0. SEPTIC TANK CAPACITY X6W LEACHING FACILITY: (type�O,,IA,,; LSI(size) NO.OF BEDROOMS T BUILDE OR OWNS PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by f � t 1c,` VX 00 1 4 TOWN OF BARNSTABLE LOCATION y��- .✓� S76C��i SEWAGE # VILLAGE ASSESSOR'S MAP & LOT-�36 (0 INSTALLER'S NAME PHONE NO.,&rZ�—,T7 SEPTIC TANK CAPACITY LEACHING FACILITY:(type)/N/iLTZid+n,j ��� (size) 7�M, 3S�s NO. OF BEDROOMS PRIVATE WELL O UBLIC WATER BUILDER OkS?? ER B£ DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No �—C:f 6 s fi s No.. _ ���" �� Fas.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH oseahon TOWN OF BARNSTABLE samstabie Department artment Alip iration for Uiripooal Wi or1w TonMrurti .erm ' �l Date - �- Application is hereby made for a Permit to Construct ( ) or Repair (,k/) an Individual Sewage Disposal System at: ..--------•--!�� N � '-------------------- c- -��u,��--------....•-•-...-------------------------....------------ ----- Location-Address Lot No. ....... �i.�� 1...... r1v' /��lN .. C �.1� / -••-"-'-'-•-----'----. --------------------•------..........•........... Owner ! AAA-r Address F�1 C-evsAl / ........... ....."---'•--•'----- ..---._................................. ___.__..____................_.. Installer Address Q Type of Building Size Lot............................Sq. feet Dwelling— No. of Bedrooms.................... ----__Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) atOther fixtures ------•----------------------------------------------............................................. W Design Flow...................5.35.............gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity_Z gallons Length---------------- Width________________ Diameter----............ Depth................ x Disposal Trench—No. _______.l.__.____ Width.......7--------- -Total Length..._u��4STotal leaching area....................sq. ft. 3 Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by......................••-•••••--•--....--•----'---_._.--'--.___.__._.____. Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fT Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ---•-•._--•-------------•---------••-•--'-..__....--•-----'•-'---..._---•'-'-"'-----.......-'--''--......................................................... Description of Soil 1 E-•----= - W M. •--•-------------------------------------•-••-•-•••..-. ....---•----•--.......-:----------•-•••-••-•------------•------ ----...._--iil! .................................................... Nature of Repairs or A erations—Answer when applicable. .�LQ_� � �T �� 7 C�` ..------..D.` i-__.___ --• O f--•----�-/N iLi 'o�C„� - tom':-%_--S77t. Agreement. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance h bee iss ed y t oard of health. Signed ............ ..... .......... .. ...�... ..� .... .. Application Approved By ... ...�......� ... :._ ..... .......... ./�� ..;. �.-:�........-......... ....� ..... v.. Dare Application Disapproved for the following year .................................................................................................... a ..... .. .................... ............. ......... Permit No. � ......... .....� ............... Issued ........f---.`........4.... . re No... J x_ Fas...`.......................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE J�j Appliration for Di ipwml lVurk,i TontitrnrtioWp rr mil Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal System at: Location-Address or Lot No. -----........................ ........--- O�cncr Address (.:611 Installer Address Type of Building Size Lot ........................Sq. feet Dwelling— No. of Bedrooms.................. --------- Attic ( ) Garbage Grinder ( ) a`k Other—Type of Building No. of ersons---------------------------- Showers YP g ---------------------------- P ( ) — Cafeteria ( ) d Other fixtures ..................•------------.------..-•----------------•---------------------------- ---•----------- •-----.-- ----------- Design Flow...................:?. ..............gallons per person per day. Total daily flow....................._............_......_..gallons. WSeptic Tank—Liquid capacity.l.?�P_gallons Length. - Width................ Diameter................ Depth................ x Disposal Trench—No. ........1......... Width.......7......... Total Length...... ..-.; ... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter...............--... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed bY----••.........---------•---•--••••--------------••-•--•--••-•-- ------ �te•--••-•••-•----•--------•---------...... Test Pit No. I................minutesp er inch Depth of Test Pit....--.............. Depth to ground water........................ ;Z4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 ••--••-••-•---------------------•-••-•••••••••--•--•••--••••••-••---------•••..................................-••.....•-•••................................. D Description of Soil.................0--"-` ..... 4.---- ....... �- ' x W --••---------•-----------------•--------•------•••••---------------------------...---••••--•----------------...-------•--•--••-•-----•----------- x Nature of Repairs or Alterations—Answer when applicable_ .-: U P � , . . �w: �1�;•f-------.. ••----.. �Qu 5� ---... ....5 ........................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance Vasbe n issued y the board of health. Al Signed -/ : ...:`....._.... ....��//h' .. �.._ .C� e Application Approved By .... .......... .. ._:... //�t'--......�....-.__a ...rT.... Yv ,�................... ...:�. .... C)............... �"� Application Disapproved for the following rear onsf ..................... ............. .. ... . ................... .................. ............................... 1 , / to Permit No. ... ..... ��. Issued /� Dace THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE TPrtifirate of TompliZ ure THIS IS TO CERTIFY, That the Individual Sewage Disposal System co�n-s-trruc"t`ed ( ) or Repaired (L< ) b �s'Uz: L., 7T..._.........._.��crLJ..-sJ<. ` /n�.�........-.._.... y .............. . ................................... ........... �/S `� Insrdler at ........................ ---...---.... Lam.-..---------- ................... ........ - ...............�.. --........ has been installed in accordance with the provisions of TITLE�(.a e E.-of The State, Code as described in the application for Disposal Works Construction Permit No. .. .••�....:.... i ..... ..........................dated ................... THE ISSUANCE OF THIS CERTIFICATE SHAH NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............................................. ............ �. . Inspector ....- .......... ................._..._............._....... - - ---.�.------ - � -- ------- --- ------ - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No.............•-- •-• FEs....`.-:.......----.... 1 t/ . Ui, peal Morkii Tono#rution rrrmit Permission is hereby granted ------- --t-SG i-`3 Q,/--`---�---------�'"��W?--- -----•----------------------•-- to Construct ( ) or Repair O an Individual Sewage Disposal System atNo........................................................ -� _v�►f ---5"%..<..�.---? < ' �...... .............. `. r Street / .11 C as shown on the application for Disposal Works Construction Permit No f-�. /�? D---- � --- � r'%�. I a^ �' Board of Hcalth�- DATE--------- ........•-1 (i I / � FORM 36508 HOBBS Q WARREN.INC..PUBLISHERS