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HomeMy WebLinkAbout0082 SHOOTFLYING HILL RD - Health 82�Shoot Flying Hill Rd. (Centerville) f OONVTR OF SACHUS `S EXECUuVE OFFICE OF EN'VIRONMEN i AL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION s VOV TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: cc_� ` ` l Owner' s Name: C Owner's Address: .1; F '� � •4t � �Ts l e � Z .� Date of Inspection: ,Z f Name of Inspector:(please print) �G `e�"�• cga Company Name:&rd.da!•Ic- �d►viJ�iRw►e ��Pet,�.aHS --- Mailing Address: 9 �; aa6�r Telephone Number: �'D5 -tx gs-_.Z 6S 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: DC Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: (_ ]Date: a? Q s The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/152000 page 1 Page 2 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A f- f CERTIFICATION �(/cJontinued) Property Address- Krz�� ,.! ( C. �CUC �.-t y e I.L�P - L Owner: v% Date of Inspection: Inspection Summary: Check A,B,C,D or E J 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: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be reel r repaired.The system,upon completion of the replacement or repair,as approved by the Board of Hea ' will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(wheth tal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is' ent System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the oard of Health. "A metal septic tank will pass inspection if it is structurally sound,no g 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 s#atic water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uae n distribution box.System will pass inspection if(with, approval of Board of Health): broken sane aced o is removed di 'on box is leveled or replaced ND explain: The system required p ping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with ap val of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSM NTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: P til, (p Owner- Date of Inspection: C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determi a 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 CM 5.303(1)(b)that the system is not functioning in a manner which will protect public health,safety a 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 alt marsh 2. System will fail unless the Board of Health(and Public W er Supplier,if any)determines that the system is functioning in a manner that protects the public Ith,safety and environment: _ The system has a septic tank and soil absorption stem(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface wate upply. — The system has a septic tank and SAS the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and S and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Me od used to determine distance "This system passes if the ell water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile org 'c compounds indicates that the well is free from pollution from that facility and the presence of amnion' nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are trig ered.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 DISIN)S AL SYSTEM INSPECTION FORM PARTC A- CERTIFICATION(continued) Property Address:�$; Owner: �b 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 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 day flow _ _r Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _ or Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public 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 f00 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.IThis system passes if the well water..analysis, performed at a DEP certified laboratory;fur cal farm 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 lei than 5 ppm,provided that no other failure criteria �f are triggered.A copy of the analysis must be attached to this form.] NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure'. E. Large Systems: To be considered a large system the system must serve a facility with a 'Raw of 10,000 gpd to 15,000 gpd. ; You must indicate either`yes"or"no"to each of the folio (The following criteria apply to large systems in additi o the criteria above) yes no the system is within 400 feet of a ce drinking water supply the system is within 200 fe of a tributary to a surface drinking water supply the system is located' a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone H of a public r supply well If you have answered"y "to any question in Section E the system is considered a significant threat,or answered "yes"in Section D e the large system has failed.The owner or operator of any large system considered a significant threat r Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The syste owner should contact the appropriate regional office of the Department. 4 Page 5 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: a �+ F 6 k t `c( }C M t// t- Owner. ��ILSc3�l Date of Inspection: Check if the following have been done.You must indicate`yes"or"no"as to each of the following: Yes No _ Pumping 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 NIA) _ 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? I _ Was the facility owner(and occupants if different from owner)provided with information on the proper nt7enance 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 CUR 15.302(3)(b)] 5 SUBSURFACE.SEWAGE DISPOSAL.Sl' T M IN EC I PART C SYSTEM INFORMATION Property Address: Sc)5 + pu_ �e t1t Ce 6 ,Z Owner: �t�vl g,�j Bate of Inspection: ( S S•'" FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): ��t7 Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no):10 [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use:(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): WO Last date of occupancy: CyYftC4 COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): apd Basis of design flXle: ersons/sgft,etc. Grease trap preseo):_Industrial waste h prese yes or no)-Non-sanitary wasd a Title 5 system(yes or no):Water meter readille:Last date of occupOTHER(describ GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no):it/D If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM J C�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 components,date installed(if known)and source of information: a.o*eon.ws Were sewage odors detected when arriving at the site(yes or no.):�O 6 Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURI+ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: t/ Owner: Date of Inspection:--2(as-7our- BUILDING SEWER(locate on site plan) . Depth below grade:_ /J Materials of construction:_cast iron _QL40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:9 (locate on site plan) u Depth below grade: Material of construction: l ..concrete 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:�1000C 1 Sludge depth: S/4` A Distance from top of slue to bottom of outlet tee or baffle: 628— Scum thickness: a Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee AAr baffle: h2 a Haw were dimensions determined: !�i°aSt// Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to Autlet invert,evidence of leakage,etc.):IZLX , k� a K ft C,kj GREASE TRAP:_(locate on site plan) Depth below grade: Material of construction: concrete metal_fibergI _polyethylene_other (explain): —' Dimensions: Scum thickness: Distance from top of scum to top of outle a or baffle: Distance from bottom of scum to bott of outlet tee or baffle: Date of Last pumping; Comments(on pumping scum ndations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evi nce of leakage,etc.): Page 8 of l 1 OFFICIAL INSPECTION FOAM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property address: Owner: ��t Date of inspection: TIGHT or HOLDING'TANK: (tank must be pumped at time tion)(locate on site plan) Depth below grade: Material of construction: concrete metal rglass polyethylene other(explain): Dimensions: Capacity: ------gallons Design Flow; gallons/ Alarm present(yes or no): Alarm Ievel: Alarm mi wo g order(yes or no): Date of last pumping: Comments(condition of al and float switches,etc.): DISTRIBUTION BOX: *4� (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: eX&t Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into r out of box,etc.): bOr as 1$vC tj fc G wi t no 6-(r2o c"� C_u rrc. 00e4 PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no - Alarms in working order(yes a): Comments(note conditio pump chamber,condition of pumps and appurtenances,etc): Page 9 of i l OFFICIAL INSPECTION_ FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSI.IRFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: S �� !/`r Pei Owner: Date of Inspection:SOIL ABSORPTION 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. 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.): 4vL.� 3 VP 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 groundw r inflow(yes or no): Comments(note co ition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on sit p Materials of constructio Dimensions: Depth of solids: Comments(note c ndition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 9 Page 10 of i I OFFICIAL,INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM f` PART C SYSTEM INFORMATION(continued) Property Address: - •� t t Qc 1 Owner:a ��K Date of Inspection:�a 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. 3t a7 f av a 7 �6 page 11 of l l OFFICIAL INSPECTION FORM—RIOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: SITE EXAM Slope -Yes Surface water *V0 Check cellar Shallow wells I/VO Estimated depth to ground water o20 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 Iocal Board of Health-explain: Checked with local excavators,installers-(attach documentation) OC Accessed USGS database-explain: You must describe how you established the high ground water elevation: 11 TOWN OF BARNSTABLE LOCAVON �bt kJn t I Cd SEWAGE# VILLAGE C Q-JQ S`S — ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type)—T� (size) C CZOg T NO.OF BEDROOMS BUILDER OR OWNER 1 "<7Y1 ca►J PEIDATE: �Z� 1.`1l COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and beeehii Facility 90 Feet Private Water Supply Well and Leaching Facility (If any wells exist f 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 CRO �Z- 36, dr3g3 �7. COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS ^ F DEPARTMENT OF ENVIRONMENTAL. PROTECTION a . � d i� byes TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE_ SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 82 SHOOT FLYING HILL ROAD CENTERVILLE, MA 02632 Owner's Name: JOANNA JONSSON Owner's Address: BOX 721 CENTERVILLE,MA.02632 Date of Inspection: 6/I1/01 Name of Inspector: (please print) ,JOHN GRACI Company Name: SEPTIC INSPECTIONS Mailing Address: P.O:BOX 2119 TEATICKET,MA. 02536 Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time,of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes _ Conditionally Passes _ Needs Fu Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 6/11/01 The system inspector shall submi a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspe ion. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments SYSTEM PASSES TITLE V RECOMEND RECOMMEND PUMPING NOW AND EVERY TWO YEARS TO MAINTAIN SYSTEM. ****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. TitiF S ImnFrtion Dorm rn VMW) ,pit Page 2 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 82 SHOOT FLYING HILL ROAD CENTERVILLE,MA 02632 Owner: JOANNA JONSSON Date of Inspection: 6/11/01 Inspection Summary: Check A,B,C,D or.E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM PASSES TITLE V RECOMEND RECOMMEND PUMPING NOW AND EVERY TWO YEARS TO MAINTAIN SYSTEM. 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,cas approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined" please explain. n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is�removed 1 3 ND explain: n/a Page 3 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 82 SHOOT FLYING HILL ROAD CENTERVILLE,MA 02632 Owner: JOANNA JONSSON Date of Inspection: 6/11/01 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(I)(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 o. 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 SASI and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance n/a "This system passes if the well water analysis,performed at a DEP certifzd laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: n/a Z i Page 4 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 82 SHOOT FLYING HILL ROAD CENTERVILLE, MA 02632 Owner: JOANNA JONSSON Date of Inspection: 6/11/01 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than Yz day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Wa. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet fi•om 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 X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any-question in Section E the system is considered a significant threat, or answered ill §C Boil D ah01,E lhi large§)%§tai hil§ The 01vur or op ralor of illly Ilry§y§16111 C010EIual a §igllifiCa1111hri al 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. a Page 5 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 82 SHOOT FLYING HILL ROAD CENTERVILLE, MA 02632 Owner: JOANNA JONSSON Date of Inspection: 6/11/01 Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No X _ Pumping information was provided ly the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks X _ Has the system received normal flows in the previous two week period`? X Have large volumes of water been introduced to the system recently or as part of this inspection ? X Were as built plans of the system'obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out'? X _ Were all system components,excluding the SAS, located on site'? X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum 9 X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no X Existing information. For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] { t• S 5 Page b of 1 1 t OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 82 SHOOT FLYING HILL ROAD CENTERVILLE, MA 02632 Owner: JOANNA JONSSON Date of Inspection: 6/11/01 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Number of current residents: 2 Does residence have a garbage grinder(yes or no): YES Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)): n/a Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CM 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection (yes or no): NO II'yes, volume pumped: n/agallons-- l low was quantity pumped determined? Wit Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 15 YEARS Were sewage odors detected when arriving at the site(yes or no): NO r . r, Page 7 of 1 l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 82 SHOOT FLYING HILL ROAD CENTERVILLE, MA 02632 Owner: JOANNA JONSSON Date of Inspection: 6/11/01 BUILDING SEWER(locate on site plan) Depth below grade: 12" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints, venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 6" Material of construction: Xconcrete=_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000G L 8' 6" H 5' 7" W 4' 10"" Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 32" Scum thickness:3" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 15" How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING NOW AND EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE SYSTEM GREASE TRAP: _(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendation's, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage, e[c.): n/a S 7 T, Page 8 of 1 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 82 SHOOT FLYING HILL ROAD CENTERVILLE, MA 02632 Owner: JOANNA JONSSON Date of Inspection: 6/11/01 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX: X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): DID NOT EXPOSE: D-BOX WHICH IS UNDER TREES-LEACH PIT HAD NEVER MORE THEN 2 FEET IN IT PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a R Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 82 SHOOT FLYING HILL ROAD CENTERVILLE,MA 02632 Owner: JOANNA JONSSON Date of Inspection: 6/11/01 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs'of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): LEACH PIT IS STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING PROPERLY. THE LEACH PIT HAS NEVER HAD MORE THAN 2 FEET IN IT.THE LEACH PIT IS OCTAGONAL IN SHAPE. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a , Page 10 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 82 SHOOT FLYING HILL ROAD CENTERVILLE,MA 02632 Owner: JOANNA JONSSON Date of Inspection: 6/11/01 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. Frr A R C o o O � a fl Page 1 1 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 82 SHOOT FLYING HILL ROAD CENTERVILLE,MA 02632 Owner: JOANNA JONSSON Date of Inspection: 6/11/01 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a NO Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of 1-lealth-explain: n/a NO Checked with local excavators, installers-(attach documentation) YES Accessed USGS database-explain: n/a You must describe how you established the'high ground water elevation: USGS MAPS AND CHARTS- 12+FEET t t 11 YOU WISH TO OPEN A SU,81NSES8? For Your Information: Business certificates cost$3D.C^-:`off years]. ,I�Y REGISTERS YOUR NAME in town (which you . (" � 4 ears . Abu ��iess c�ertlf�a ;. „ ! must do by M.G.L.-it does not give you permission to uperate.j YOU must first obtain the necessary signatures on this form at 200-Main St. Hyannis. Take the completed form to the Town Clerk's Uffic e, 1 st FI. .367 Main St. Hyannis, y}annis ti1A 02601 required-by law. (Town Hall) and get the Business Cerfificate.that is - #, z OATE d ` t � _N APPLICANT'S -,� l Fill in.please: � 4 k YOUR NAME/ BUSINESS YO.IR HOME ADDRESS: TELEPHONE # Home Te;ephone Number NAME OF.CORPORATION: NAME&NEW BUSINESS �� : / -_ G _ 1. TYPE OF.BUSINESS IS THIS,.A HOME OCCUPAT Oil`.. ADDRESS OF BUSINESS Z NIAP/PARCEL NUfirsBER IQ t_ _ ttis5esslr:gj ��_ When starting a new business there ?re sq veral things you must do in order to he in r^.,,��,�„� .he rules rr�;alu*,nr• 1 o Sn .. s . you is� obteir g information o. msi �t d^ � . � ti•:: }t ? '.�. �f71.�i.aLf�'i oT Y�.`Y ;;•fi'�'�.;;i�l SVtic3 c S� .::s.�'C`.'"f'..f. Gr chi t;'EC.1??.is arnst e. h!s form i� intended ty u have the apprap ,o,, permits ahid licenses vequired to pFg�;,},��,e,'mot;fi eu� ;,ush.i Rom. �..IVialn Street to make sure rya hay � _8s trl MIS:tov�rit;° .. ._: ... . 1. BUILDING COMMISSIONER'S OFFICE This individuai has been informed of'any'permir,renuirements thai nartain to this ty Go r _. ��.. nf'h in�c� Authorized Sian r COIL NII�NTS. 9 .. 2. BOARD OF HEALTH This individualh `b='P eLn i nf /j'P �:n.rT r t i t ,` ,R . t . t' it ; _....,_. .._. �,vi,•.w.r"��. . Authorized Siynatu a LYVIRi'I�q(tt . �ZARDOU S COMMENTS: �' ,T ,1'ERIALS REGU L14:11 ONS 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has 'I'. n informed of th?licensing IfL ra ;i;�� ont7 than pG:'�Zi _ S,``1G_- ofr Authorized Signature COMMENTS: