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HomeMy WebLinkAbout0022 RICHARDSON ROAD - Health 22 Richardson Road Centerville P A = 209 016 i i UPC 12534 No. 2R gpOST•GON'v�� HASTINGS, MN ICI ur-stf)6� Hofr►e TOWN OF BARNSTABLE LO ATIONaLiT .M A ct t^d g Orl SEWAGE# VILL,AGE C/!f-eP✓i L1 e ASSESSOR'S MAP&PARCEL,7oQ— / O(o INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY.(type) (size) NO.OF BEDROOMS OWNER aeRC rrrat r,t; Cy P Z- 0 C/I te r t,i L L e J.L PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on sits;or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within x 300 feet of leaching facility) Feet FURNISHED BY I (/2 sxrNwaq i�z GLACE i- CtCµVYT1 ( `q r F..�/CNAkQfDN RO. SAS_! 'ENTER v21E.MA. j nI Vb YR.PYW6r) ; �j C NarE: WArzc ez 4N7[FJ AL06. \\\b JMN CZ ,a �p PLAN yA . Commonwealth of Massachusetts Title 5 Official Inspection Form , Subsurface Sewage Disposal System Form -Not for Voluntary Assessments o2e2 �iG�/ sZDSo� �oIf,;, , '�/'o ZU//- 4/4xf --9-44�1f,4z Fs'4 Cy Property Address Owner Owners Name information is C�fiS/Tf/L1�lLL¢" 0,24 .z 21,23111 required for every 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: A. General Information (n When filling out forms on the computer,use 1. Inspector: only the tab key to move your cursor-do not Name of Inspector. use the return key. Company Name Company Address City/Town State Zip Code Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: Passes ❑ Conditionally Passes ❑ Fails CD ❑ Needs Further Evaluation by the Local Approving Authority :2123/ I , r �� Inspectors Signature Date CD The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or . has a design.flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. C� 3 1 t5ins•09108 ..._.. Title 5 Official Inspection Form:Subsurface Sewage Disposal Sy m•Page 1 of 17 Commonwealth of Massachusetts f Title 5 Official, Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is C�h�TfyZ!J/L L F required for /I�,� U-Zla every 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 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: /fLlG J AA/* c f. 49 eer-o;w-1Wf dnr S X✓ ,,y Nfp ALJ6 /✓liq B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N,.ND)for the following statements. If not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address /3fvc�sy�-na �..ssrsTfo,(/y/.�.c Owner Owner's Name information is required for [� every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) N� B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): �d 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 t5ins•09108 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 /G/ T0. Property Address Owner Owner's Name / information is CE.�rM�S,S, U,2G32 required for every page. Cityfrown State Zip Code Da f Inspection B. Certification (cont.) 2.. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and.soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 ❑ [X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool [hGWf Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ❑ //,j Liquid depth in cesspool is less than 6" below invert or available volume is less than '/Z day flow l5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments lug Property Address Owner Owner's Name information is C¢jy/Tf��/LLf 17032 ���� required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ N 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. El ❑ �� Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ❑ //h Any portion of a cesspool or privy is within a Zone 1 of a public.well. ❑ ❑ *4 Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ❑ AA 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.] ❑ El 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 system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, im ust 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 El the system is located in a nitrogen sensitive area (Interim Wellhead Protection El the —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. t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Addr s / ys�cfrfygak. SiSTf� ,Ziv�.s�� L.1-.1 Owner Owner's Name information is ��v�LLf AYIJ5s , p,2 2 -Z/"// r required for 153 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No. [�] ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ 'Has the system received normal flows in the previous two week period? ElHave large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs of break out? ❑ Were all system components, excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? © ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ 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): t5ins•09108 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 Property Address / L�<• Owner Owner's Name information is required for c-• every page. City/Town State Zip Code Date of Inspection D. System Information Description: 1-114 Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ❑ No 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: Dat�c��/�9 Commercial/Industrial Flow Conditions: Type.of Establishment: based on flow Design 310 CMR 15.203 : l9a� g ( ) 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: /f, r25-O t5ins•09/08 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 Property Addr}ss Owner Owner's Name information is y, f 0 26 14 required for C• / every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) e/ Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 02fr1f5f # if//O 7/J.(/'rry,� ST�Ifs,p►3f,Q Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: yaw t Septic tank,6istribution box oil 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 or 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Addres �fyc��s�i2.� �ssis9f� 2i�iyc L.L,l _ Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: GII��s f 7X V P .2 /AS D /fQb� /Fy l Zj1 n Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): �pia H Depth below grade: 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 G/1 Material of construction: FV concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 5711- 41 All Sludge depth: .t5ins•09108 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts I Up- /z/ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address /�3�•Y���s,��,� , y x/L Owner Owner's Name information is f/�r���y/Llr � 5 2127J I� required for O29 :72 every page. Citylrown 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 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 �lf�Stiai.vc^r�t� 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.): _ /ZEcco+�� a— jryy Al 4ysrss° DST[�� i.�/vs'/Z7 +Ud�S6Gtis ,C 6�lr/Ai Grease Trap (locate on site plan): rade: /// ~Depth below p g feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 31D oo G,f i✓ S'' �'t+�' Dimensions: Scum thickness y� 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 QuTrz GdO07 STi�yG��G/dLIV t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 17 So,rIX� � �/�'!//�•1Gd��G F E'N r,1/Vo£it- 7-/V7-E i5� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not fo,r.Voluntary Assessments e2z O�icy�r�so� �✓ Property Addr��jjss ��L e' Owner Owners Naglq information isFf�yi«F �iSS' 26 3Z z123�1� required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): �vn►slyE7 /tlb/Vel Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: gallons Design Flow: gallons per day ' Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins-og/otI Title 5 Official Inspection Form:Subsurface Sewage Disposal System Pagel 1 of 17 Commonwealth of Massachusetts - L Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address �.�c,�� sS/sue •Ciy�.s�6 .L.L.< Owner Owner's Name information is required for �f''s/��iz��«r ' /�✓ � D�G3Z 2�z3�.�� every page. CityfTown 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 ' 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): Pumps in working order: E] Yes ❑ No Alarms in working order: [ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments yt 2' A�C�T �l��y Property Address Owner Owner's Name information is G 3 2 2`23�j! required for e every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers. number: ❑ leaching galleries number: EXleaching trenches number, length: /2 P.✓oo�a �G C'i�s"�� ❑ 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.): Ib �� i� ILI 1t trV. c) �oic /S ,rlt D ,�'/•s/� ,S/�•U/� pcfZ afG/�iOrT/b•`i 3r 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 ❑ No t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts . Title 5. Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Add re s Owner Owner's Name information is ���s/TfiLUlLL /1' 7 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 1lro,�f 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.): t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Name information is /�yr��yy/LLr /�f,�,Ss, pg�3Z required for C- every page. Cityfrown 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 . t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 121 G ff /21754� Property Addre s Owner Owner's Nam information is �� r required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: Slope Check L S (� Surface watery,vim ® Check cellar Vi5 ] Shallow wells ,( ,9" 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•09108 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 Property Address Owner Owner's Name information is �Ff/ZddLLf /yes• required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked* Inspection Summary D(System Failure Criteria Applicable to All Systems) completed �] System Information—Estimated depth to high groundwater [� Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09/oB - Title 5 Official Inspection Form:2UbGUrfaCe Sewage Disposal System•Page 17 of 17 Your 1 I I How 1 It is important to understand how your system works and how this treatment affects it in order to protect your investment.The typical system consists of three (3)main components. The Septic Tank The Distribution Box The Drainfield The Septic Tank Waste exits the house and enters the septic tank where solids settle to the bottom, grease and scum from the household detergents float to the top, and liquids stay in between. The solids that settle create their own bacte- ria which decompose the solids naturally..There is no need to add additional enzymes and bacteria to the tank. The tank eventually fills with solids and scum requiring it to be pumped.A septic should be pumped every two (2) years. The Drain geld The liquid (gray water) flows to the distribution box where it is evenly dispersed into the drainfield. Finally,the drainfield begins treating the gray water. Microorganisms in the soil consume organic pollutants in the gray water and the pure water is absorbed by the ground below. How Problems Start From the first day of use, the drainfield of your septic system begins to deteriorate. Some solids,grease, and scum always pass through the septic tank into the laterals. This is because of natural solu- bility or the lack of setting time in the septic tank during periods of heavy use. Problems especially arise when the septic system is not maintained and the septic tank fills with solids and scum that overflow into the drainfield. As the drainfield becomes clogged,the water flow becomes restricted. Since the water cannot drain into the soil, it filters upward causing ponding, foul odors, wet spots in the yard, and an unhealthy envi- What Causes Problems What you don't read about is that bacteria has a waste called biomat, and they also create a gas, bacteria eats human waste. It does not eat, hair, wool, polyester and other particles. The biomat is like grease. The gas cre- ates bubbles and this causes particles to float up the T and into the distribution box and into the leeching fa- cility,plugging up the stone. Septic tanks should be pumped every two (2)years. Cesspool Cesspools were made by digging a hole in the ground and walls were made of stone then later on they were built with concrete blocks. The waste entered the cesspool, and solids settled to the bottom, the liquids seeped out the sides into the soil. Cesspools should be pumped every year. State Environmental Code Title V Chap. 5 Inspection Procedures Guidance on Completing Inspection Form Part A Certification. The Certification Section has two principal functions. First it provides identification information on the property being inspected and the inspector. Second, it presents the results of the inspection relative to the failure criteria outlined in 310 CIVIR 15:303. In the certification statement, the inspector is certifying that the conditions existing at the time of inspection are accurately presented in the inspection report. The inspector is not certifying that the system is adequate for the current use of the system nor for the future use of the system. TONY CAPONIGRO 216 North Main Street 1\4'ansfieid, MA 02040 Title V Inspections , OZfI (f�Oil lt: ld h A X 1b1 (b2bb000 WILMLKHAL.E toQ111015 OFFICI.A L INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE I)ISPGSAL'SYSTEk INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ? Owner: Dale of Inspet'lion, SKETCH OF SEWAGE]DISPOSAL SYSTEM! Provide a sketch of.he sewage disposal system including tics to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet Locate where public w2ter supply enters the building.. SAS-2 elz 'rldt;NCM�i,� ERM/1-4,' ,";'cA aa4w4lr 1 MA. N` 7,15 -- (fit p$,- Clov 9AS7JlDE / kALV6 Cq o ►� 0- Q FCC-! 0s 1 -z O 0 Icy f - -r;t� <Tom„«.,•.;,.,, P—mg AFC 4r%'W%At t() _ V'Li I fiZV I I I f :2V rAA lbl fbZU�VVV W IL.I4LKHALL �r�014io1b PRINCIPLES OF ONSITE SEWAGE DISPOSAL System Components & Fiinction e Grease Traps (cunt.) b. Differences from septic tanks -inlet tee extends to raid-depth outlet tee extends to within 12 inches of bottom minimum capacity of loco gallons PRINCIPLE; OF ONSITE SEWAGE DISPOSAL System Components & Func.-tion e Grease Taps (Cont.) c. Grease floats to top d. Inspection/Maintenance Requirements -inspected monthly cleaned every S months cr when grease is 25% of effective depth, whichever is,sooner PRINCIPLES OF ONSITE SEWAGE DISPOSAL System Components & Function ® Soil Absorption Systems (SAS) a, provides treatment of septic effluent 1) Removes contaminants -pathogenic organisms (bacteria, viruses, protozoa) -Biological Oxygen ®errand (50C) -Total Suspended Solids (TSS) _ 1 � a COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM n PART A CERTIFICATION Property Address, /2/C,�/J/ZdSD� Owner's Name: IVA"C j� � :f V/.4 Owner's Address: ayepx!£s/f- 1Ll• SSA D�4ff/ '390 Date of Inspection: Name of Inspector: (please print) Antonino Caponigro Company Name: Tony Caponiaro' s TnqQPrt i n Service Mailing Address: 216 'North Main St Mansfield, Mass . 02048 Telephone Number: ( 508 ) 339-821 9 CERTIFICATION STATEMENT 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 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: 7 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 dic system is a shared system or has a design flow of 10,000 gpd or greater,die inspector and die system owner shall !,nbniit the report to die 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 Continents ""•Tliis report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how1t1%e*s(e0, wilhp`er"fW"'07 the future under the same or different conditions of use. Title 5 Inspection Forni 6/15/2000 page I f � I 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. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR I 3 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: N,/ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes, no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent:System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal iseptic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Cf�/ltl2l�l,CLf. zy...VSS' Owner Date of Inspection: 711 o7 C.11llFurther Evaluation is Required by the Board of Health. ND Conditions exist which require father 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 I 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 front a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,.provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other_ 3 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: ?,2 /ClLff/�1U�D.y Owner: " Date of Inspection: D. 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 or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool 1 0/✓f Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool AIA Liquid depth in cesspool is less than 6"below invert or available volume is less than 'fi 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. AIA Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. NA 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. 11A 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 ppn4'provided'that uo 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: AIA, 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 11 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 . U1-FICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: pL/C/f.C1'/1tJ.S�// �G✓� FiS/TF/ZUJ.L1f. /�1.155' Owner: Date of Inspection: /iSfy" Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No Pumping information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system.obtained and examined?(If they were not.available note as N/A) _ Was the facility or dwelling inspected for signs of sewage back up? _ Was the site inspected for signs of break out? ✓1 _ 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..bafflesoriees,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 tl'e failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 2- /1e't1' 1z'0.5r'W Owner: Date of Inspection: 7//S/y7 —�� FLOW CONDITIONS RESIDENTIAL Aw Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms): 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 no): Seasonal use:(yes or no):_ Water meter readings, if available(last 2 years usageXgpd)): Sump pump(yes or no):_ Last date of occupancy: DCC!/P/F'p ,¢T COMM ERCIAL/INDUSTRIA L Type of establishment: /YaX,S live I-JP V f Design flow(based on 310 CMR 15.203): fob; gpd Basis of design flow(seats/persons/sgft etc.): G /1F .0 /S�G/V m,lg#;OQDoN . Grease trap present(yes or no): fs Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): G•`� Water meter readings, if available: S',/mo 4:9.040 1W Last date of occupancy/use:o / 7.ly OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: �o7-/M,eo,IV Was system pumped as part of the inspection(yes or no): AD If yes, volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,dire�ox, soil absorption system Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: SySTF� /9yQ' Taa�ir/�ttC!/` «Y4s-rA40 Z IV-0 q yOf O.410 Were sewage odors detected when arriving at the site(yes or no): 6 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: N Cf'�l/Tfi2!>/,LL f lY•�,�5� Owner: Date of Inspection: ?�Zo 7 BUILDING SEWER(locate on site plan) Depth below grade: Z. f Materials of construction: _Lwast iron _t_40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints, venting, evidence of leakage, etc.): C D1VDir-io.y o-fi J of vr'S `!/fNTi�6 60046 SEPTIC TANK: p ,(locate on site plan) Depth below grade: _ -r Material of construction:(concrete_metal_fiberglass polyethylene _othcr(explain) If tank is metal list age:_ Is age,confirmed by a Certificate of Compliance(yes or no): _(attach a copy of certificate) Dimensions: -2 ;2 3iO4,9 �i 4f.0 f 0 Sludge depth: "AIA /- /o'er. H 2 /r Distance from top of sludge to bottom of outlet tee or baffle: -X/ /.3'�, z /z Scum thickness: d/—y Distance.from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: /.z'y b z 21z ', How were dimensions determined: ,Vf,F5d.4,y QN .SITE Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of.leakage,etc.): /N.CET 4 O//TL. fT 715 GDe /2 ST,er/c7'41/WeY So2aAlp Fyf�/ l� iTry DtlT,CET /�S/dE/LT yo f!I/T��iylF o .CF.d.���y6 �E�Cd��.VD T.4!✓f� .CAE G��/�•�EO ly/Ti�ri.y y rya �d��Y 1 y/ZS, T•`/feE.�F7 GREASE TRAP: (locate on site plan) 4;:�d fdS£ 9"/ll1.a S.S'ot/.i D '?f' pW-4%00' g Eels Depth below grade: Material of construction: y concrete_metal_fiberglass_polyethylene_other (explain): 'i Otf /T� FXTF/f/s/O�y �� Al;,— Dimensions: 3 pdo ri,d L r dll boa �6/�!�/•5/6 Scum thickness: ... Distance from top of scam to top of outlet tee or baffle: 8 Distance from bottom of scum to bottom of outlet tee or baflle:3.1 " Date of last pumping: / �Z/1 G p Comments(on pumping recommendations, inlet and outlet tee or baffle_condition,.structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 6� yNV f y- D urt f T?S 4d4-i- s7,7,Wr,/NT. 49105O">. "aFG 7 I OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner- Date of Inspection: / Xc> T GHT 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/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: (if present must be openedxlocate on site plan) Depth of liquid level above outlet invert: Comments (note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box etc.): s PUMP CHAMBER: y (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): f Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.): 8 . o d OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ,22 "V/C�.fA/Z/7.50"/ Owner: Date of Inspection: 7 /V1 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located explain why:_ Type leaching pits, number:_ leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: inn ovativc/alternative system Type/name of technology: m Coments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): V14 /S /L/�!J. . /�✓j S/1N/J 02 //E�f7f�T/O�/ 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 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS v. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: .22 /2lCf-!,K xP,5,;-P V P,ct 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. sco ,S' � v4r�� •rr. vai'W da Cf 010J. 4A 44,yry w 4a, ►b!A_ IAA S.VC � i P_C-,/ 0 q "A it .� I Ali New rC.2 A.LS, 10 OFFICIAL. INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SOBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART C SYSTEM INFORMATION (continued) .Property Address:' �2 �1C/,�.E.rtbSaY Pc� way Owner: Date of Inspection: 7 i S"- p SITE EXAM Slope ;E-"/-.bT f<� Surface water Check cellar Shallow wells /VoNf .Estimated depth to ground water t/! 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 holc within 150 feet of SAS) Checked with local Board of Health-explain: Checked'with local excavators,installers-(attach documentation) Accessed USGS database-explain: e. You trust describc how you established the high ground water elevation: State Enviromental Code Title V Chap. 5 Inspection Procedures Guidance on Completing Inspection Form Part A Certification. The Certification Section has two principal functions. First it provides identification information on the property being inspected and the inspector. Second, it presents the results of fie inspection relative to -the --fai-iure--c-it-er- a outlined in- 310 CMR 15t303 . In the certification statement, the .inspector is cer- tifing. that the conditions existing at the time of inspection are accurately *presented in the inspection report: the inspector is not certifying that the system is adequate for the current use ,of the system. nor for the future use of the system. it - Y01114 Siontic System and How it W6rks ' ;, It is important to understand how your system works and how this treatment affects it in order to protect your investment. The typical system consists of three (3) main components. The Septic Tank The Distribution Box The Drainfield The Septic Wank Waste exits the house and enters the septic tank where solids settle to the bottom, . . grease and scum from the household detergents float to the top, and liquids stay in between. The solids that settle create their own bacteria which decompose the solids naturally. There is no need to add additional enzymes and bacteria-to the tank. The tank eventually fills with solids and scum requiring it to-be pumped. The Drainfield The liquid (gray water) flows to the distribution box where it is evenly dispersed into the drainfield. Finally, the drainfield begins treating the gray water. Microorganisms in the soil consume organic pollutants in the gray water and the pure water is absorbed by the ground below. How Problems Start From the first day of use, the drainfield of your septic system begins to deteriorate. Some solids, grease, and scum always pass through the septic tank into the laterals. This is because of natural solubility or the lack of settling time in the septic tank during periods of heavy use. Problems especially arise when the septic system is not maintained' and the septic tanks .fills with solids and scum that overflow into the drainfield: As the drainfield becomes clogged, the water, flow becomes restricted. Since the water cannot drain into the soil, it filters upward causing ponding, foul odors, wet spots in the yard, and an unhealthy environment. \_ TONY CAPONIGRO -k 216 No. Main Street Mansfield, MA 02048 Title V Inspections . Vi/Vi/GVVt 19 :0 tAi". lb1foLlbO UV ?11Lh9LhjHHLt. tM,VVb� V14 09726/2®04 14:28 50833987�6 F} g PfJ 1NQiPLES OF ONSITE SEWAGE QI PO SAL jerA Components &FwntliOn � Traps (Col 8 ° y� b. Differences from septic tanks -inlet tG9 extends tad mid-depth _outlet too extends to Withir' 12 Inches of b to�f �QQQ ��#It�r�� -minimum capacity -� PRINCIPLES OF 0NSITE SEWAGE DCSFQSAL Syjjt romponert! &FuMlion Grease Tr pS (coat.) a. GrQa3Q f109tts tO tap _ d. InSp&Ction/MaInteMnce RR9quirernents -inspected monthly ®cleaned ever' 3 months or when r* 6 Is 250/a Of effective depth, hichovsr is.soo►ner PRINCI OF ONSITE $EWAGE DIs PO SAL e ��rnpsnentr,&N . Provides treatment of 5001C GfflusTlt t) Removes contsminamts -pathogenic organisms (bacteria, viruses, protozoa' . 1010 is&I oxygen Derftnd (SOD) Total Suspended SoIW5 (TSS) 1 : Town of Barnstable OF fHE Tp� Regulatory Services aaxrsrnsie Thomas F. Geiler, Director Masi. g 16 3.r Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the"Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ' A , OCT 0 6 2004 T TOWN OF BARNSTABLE TITLE $ HEALTH DEPT. OFFICIAL IIJSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: MAP ��iS/7'ff2l�I.C,(F. .ASS• PARCEL, ;- o Owner's Name: C Owner's Address: 35— Sr Date of Inspection: _ gZ2f D Name of Inspector: (please print) Antonino Caponigro Company Name:. Tony Caportiuro' s Tnsnect-i nn Service Mailing Address: 216 North Main gf: , Mansfield, mass. 02048 Telephone Number:_ (506) 339-821 9 CERTIFICATION STATEMENT I certify that l 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 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-�nbmit 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 N/� ****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 Forn: 6/15/2000 page I r OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A , CERTIFICATION (continued) Property Address: �72 Ivey IV7- d/,GIF Owner: ee6te= WI-Al" .�C Date of IOspedion: Inspection Summary: Cbeck A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: /Y I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: NXS f to Sff D a.4 V e X! o uJ d ,0WAYS B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal°septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or, obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: NC41/"WA Date of Inspection: 2 D C. Further Evaluation is Required by the Board of Health: PP 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 froal a private water supply well•'.Method used to determine distance ••This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: oZ2/Z/C.�/� t1JSLy✓ . C �4/T ,ev/�c .l1S5 Owner: fNl//I�.drlNTf'.Gl� .«C Date of Inspection: D. 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 or system component due to overloaded or clogged SAS or cesspool J Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ,LR Static liquid level in the distribution.box above outlet invert due to an overloaded or clogged SAS or cesspool NA Liquid depth in cesspool is less than 6"below invert or available volume is less than'%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. A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. NA 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. �A 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.) /V y (YeslNo)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 oAmer should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: `v 14 1 To be considered a large system the system must serve a facility with a design now 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 11 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 . :i OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: �� /�/C�//�IIOSDiY .mod• �'!!if/Tf�'!/lrJCt �1aSS Owner: d"e,S/—W,W� - -Lw�/J<,4f- C.I� Date of Inspection: 9/2L/O Check if the following have been done. You must indicate`yes"or"no"as to each of the following: Yes No Pumping information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeks? _ I ias 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? X. _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _ Was the facility or dwelling inspected for signs of sewage back up ✓X _ Was the site inspected for signs of break out? X. _ 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 v _ Existing information. For example,a plan at the Board of Health. V _ 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 OFFICIAL 1NS�ECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Fd, C 9C1,/7-f;_X ui crc 16.0*S-5.e . Owner: wi/zae . X C Date of Inspection: g,T�D y FLOW CONDITIONS RESIDENTIAL �,,� Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 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 no):_ Seasonal use:(yes or no)._ e Water meter readings, if available(last 2 years usageYgpd)): Sump pump(yes or no):_ Last date of occupancy: COMMERCIAL NDUSTRIAL Type of establishment: /.dS?ir�J/Yo�✓,14 Design flow(based on 310 CMR 15.203): %90a gpd Basis of design flow(seats/persons/ gketc.j w1A t(APOPCk'S Grease trap present(yes or no): !s 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: , ,," dA4,0r. _!r,,6G0 6je;/' Last date of occupancy/use: Agw^ezzy ".v W491 Lre-ze"" OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no):�! �lN.l�/N �'d^ S�Job��`✓a•r If yes, volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tanlf ,soil absorption system _Single cesspool Overflow cesspool —Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: ;Ggd ;-.406f >.e�/somas Sysrf.y iivsTi�.u�o �9 9'S Z�.D.!/1ZEcoa a3 Were sewage odors detected when arriving at the site(yes or no): 6 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ,2.2J2d- CFiVTF/d✓/�.Cr. /1�SS Owner: F•YlNAl,P-/lf<—<f�Tf/IVIA F 4,4 C Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: ?•,3" Materials of construction:_Xcast iron Y 40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): �oNDly`io rc� a� �"OlN7''� >j df�yr/mod G D o � Xh Ed/Dft�C�D.C/F���E s SEPTIC TANK: �L(locate on site plan) Depth below grade: 71-r'Tti k" Material of construction:,concrete_metal_fiberglass polyethylene _othcr(explain) if tank is metal list age:_ is age confirmed by a Certificate of Compliance(yes or no): _(attach a copy of certificate) Dimensions: 2- 7www5 23 Sludge depth: S-r 17- Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: sr/_ 4" 5T2-- S""' Distance1rom top of scum to top of outlet tee or baffle: ST/ /.?'' S? Z /Z , Distance from bottom of scum to bottom of outlet tee or baffle: S l'/- Z'Y How were dimensions determined: -1z' Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): /,v.c F r 4 O1/7-�4 FT Ts /D O D srevc 7-469&,,Y So a vo ,L/Qa/b ,C FvE�- iWiF,Y lv/TfH z%17-x E 7- /NC/F/z T yo -!F /Iy6wy c -0:1C .CF.r1.� 2E fCd/tl f.VD 71.41/✓/<' .CAE GREASE TRAP: '1 (locate on site plan) lvelv Depth below grade: Material of construction: A concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: 3,006 44.1- Dfile Scum thickness: (r' Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: 3';2 Date of last pumping: :?yes 1442) Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): IA14 9'7- J. DUT.0 P'T //cP!?/D 1-frlaf-L afN aor/rr ours Frli�iyp,Z? �f F,t,�s`r�is�y won c.�ja viva s�/sfou� f .�F�u/n FD 7 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ga FNrF.G disc F. ,yd4ss Owner: Date of Inspection: G O 1 ��T GHT or HOLDING TANK: (tank must be Pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethvlene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be openedxlocate on site plan) Depth of liquid level above outlet invert: Qur.AEr/.vdfrr` Comments(note if box is level and djstribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): d / G < PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): F Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: i—fA rF.evi u f, Motes Owner.• 6L Date of Inspection: p SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why:, Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: fA leaching trenches,number,length:_/�—/DO' /G —/-?,j''F6 leaching fields,number,dimensions: overflow cesspool,number. innovative/altuitative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): �� S/�ys Dom' .4�YD�•+�li.C/� F.�,�li/lf iYb i/JO,�O/.,•� ,qua D.t/.yos0/L SO14 1-5 15' lyirA'ff/mil 02 {�E6fTi�T/Oil/ Awn Aid CESSPOOLS: (cesspool roust 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,e(c.): 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 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION(continued) Property Address: ?2 AFd C�NTF/l d//,.0 .t1.as5 Owner: n&l7reolu 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. SAS-2 \ C/Z 7�R�NcNest� - cc�,�,t�ovT• ,PZA ` SAC-/ 6 F 1 v� ON EAS 7-,3/pE 11Ac.v6 Tj t 2 O O IN Ct�(IF/ZS TD Gi2/�Dl 2�3�� L 1 P I•4 N �I NoY 7o SCAI.ti �, �• . V� 'r; l. S T.o,.••r; .,.F...w.hliS�(1lV1 10 rr OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART C SYSTEM INFORMATION(continued) Property Address: CFNTF11 a1 l.CC �54t< � Owner: ' ?3fN�,�/yt�/l/.c�FiY/TFiC�d/•C•CF.C.C�' Date of Inspection: SITE EXAM Slope ,(!�-7- /—'/F�vS T'o S/!7F Surface water ,Vt7,t* Check cellar Shallow wells .Estimated depth to ground water 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: S 2 q6 Obsmed site(abutting property/obscrvation hole within ISO 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: 4"T W6U C. XA1JA/S State Enviromental Code Title V Chap. 5 Inspection Procedures Guidance on Completing Inspection Form Part A Certification. The Certification Section has two principal functions. First it provides identification information on the property being inspected and the inspector. Second, it presents the results of the inspection relative to the fa-.ilur-e- criteria- outlined in 310 -------; CMR 15 :303 . In the certification statement, the inspector is cer- tifing• that the conditions existing at the time of inspection are accurately 'presented in the inspection report: the inspector is not certifying that the system is adequate for the current use ,of the system nor for the future use of the system. ll . Your Septic System alid How it Works is important to understand how your system works and how this treatment affects in order to protect your investment.. The typical system consists of three (3) main mponents. The Septic Tank The Distribution Box The Drainfield "he Septic Tank taste exits the house and enters the septic tank where solids settle to the bottom, . . rease and scum from the household detergents float to the top, and liquids stay in etween. The solids that settle create their own bacteria which decompose the solids aturally. There is no need to add additional enzymes and bacteria to the tank. The ink eventually fills with solids and scum requiring it to•be pumped. "he Drainfield 'he liquid (gray water) flows to the distribution box where it is evenly dispersed into ie drainfield. Finally, the drainfield begins treating the gray water. Microorganisms i the soil consume organic pollutants in the gray water and the pure water is absorbed y the ground below. low Problems Start 'rom the first day of use, the drainfield of your septic system begins to deteriorate. ome solids, grease, and scum always pass through the septic tank into the laterals. 'his is because of natural solubility or the lack of settling time in the septic tank uring periods of heavy use. Problems especially arise when the septic system is not Zaintained and the septic tanks fills with solids and scum that overflow into the rainfield. As the drainfield becomes clogged, the water flow becomes restricted. 'ince the water cannot drain into the soil, it filters upward causing ponding, foul dors, wet spots in the yard, and an unhealthy environment. ,k TONY CAPONIGRO -k 216 No. Main Street Mansfield, MA 02048 Title V Inspections / 2 J PRINCIPLES OF ONSITE SEWAGE DISPOSAL System Components & Function • Grease Traps (con't.) b. Differences from septic tanks -inlet tee extends to mid-depth -outlet tee extends to within 12 inches of bottorn -minimum capacity of 1000 gallons PRINCIPLES OF ONSITE SEWAGE DISPOSAL System Components & Function • Grease Traps (cont.) c. Grease floats to top d. Inspection/Maintenance Requirements �- -inspected monthly -cleaned every 3 months or when grease is 25% of effective depth, whichever is.sooner PRINCIPLES OF ONSITE SEWAGE DISPOSAL System Components & Function • Soil Absorption Systems (SAS) a. Provides treatment of septic effluent 1) Removes contaminants -pathogenic organisms (bacteria, viruses, protozoa) -Biological Oxygen Demand (BOD) -Total Suspended Solids (TSS) 1.2 A