HomeMy WebLinkAbout0070 WOODVALE LANE - Health 70 WOODVALE LANE, CENTERVILLE
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Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
70 Woodvale Lane
M
Property•Address
Lisa Summers
Owner Owner's Name
information is
required for every. Centerville MA 02632 10/10/13
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 comp leteness.checklist at the end.of the form.
Important:When A. General Information -
filling out forms
on the computer, .
use only the tab -
key to move your
1. Inspector:
f
cursor-do not- Matthew Gllfoy. I V
use the return
key. Name of Inspector
B & B Excavation,Inc.
Company Name
14 Teaberry Lane -
Company Address
,ate Forestdale MA . - 02644
City/Town State Zip Code
508-477-0653 S113640
Telephone Number License.Number
B. Certification
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
. _ _....
Needs Further Evaluation by the Local Approving:Authority
turf:
10/15/13
Inspector's Signature - - . Date : -The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or.DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design.flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The originalshould 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.
�0�? LY
t5ins-11/10 Title 5 Official Inspection r Subsurface Sewage,Disposal System•Page 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
70 Woodvale Lane
M
Property Address
Lisa Summers
Owner Owner's Name
information is required for every Centerville MA 02632 10/10/13
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 70 Woodvale Lane
Property Address
Lisa Summers
Owner Owner's Name
information is required for every Centerville MA 02632 10/10/13
page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 70 Woodvale Lane
Property Address
Lisa Summers
Owner Owner's Name
information is required for every Centerville MA 02632 10/10/13
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® 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 Y2 day flow
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° 70 Woodvale Lane
M
Property Address
Lisa Summers
Owner Owner's Name
information is required for every Centerville MA 02632 10/10/13
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® 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 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CM 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, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area— IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspec ion Form
_ Subsurface Sewage Disposal System Form Not for Voluntary Assessments
°r 70 Woodvale Lane
'M
.. Property Address: ...
Lisa Summers
Owner: Owner's Name
information is required for every Centerville MA 02632 10/10/13
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
❑ N 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
El M
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?
I
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): 2::_: Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203.(for example: 110 gpd x#of bedrooms): _ 220
t5ins•11/10. Title 5 Official Inspection Form:Subsurface Sewage.Disposal System•Page 6 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 70 Woodvale Lane
Property Address
Lisa Summers
Owner Owner's Name
information is required for every Centerville MA 02632 10/10/13
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
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
Seasonaluse? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: May 2013
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•11/10 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
^M 70 Woodvale Lane
Property Address
Lisa Summers
Owner Owner's Name
information is required for every Centerville MA 02632 10/10/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ❑ No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no)(if yes, attach previous inspection records, if any)
❑ 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 70 Woodvale Lane
Property Address
Lisa Summers
Owner Owner's Name
information is required for every Centerville MA 02632 10/10/13
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1'6"feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: >10'feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
At time of inspection building sewer appeared to be in working order. No sign of leakage or blockage.
Septic Tank(locate on site plan):
Depth below grade: 1
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years.
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ® No
Dimensions: 1000 gal
Sludge depth:
4"
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 70 Woodvale Lane
Property Address
Lisa Summers
Owner Owner's Name
information is required for every Centerville MA 02632 10/10/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
30"
Scum thickness
1"
6"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle 16"
How were dimensions determined? scour stick
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
At time of inspection septic tank appears to be structurally sound. No sign of back-up.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 70 Woodvale Lane
Property Address
Lisa Summers
Owner Owner's Name
information is required for every Centerville MA 02632 10/10/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 70 Woodvale Lane
Property Address
Lisa Summers
Owner Owner's Name
information is required for every Centerville MA 02632 10/10/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert
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.):
No d-box
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes . ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
70 Woodvale Lane
Property Address
Lisa Summers
Owner Owner's Name
information is required for every Centerville MA 02632 10/10/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
I
® overflow cesspool number: 5 x 5
❑ 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.):
At time of inspection leaching/cesspool is dry and appears to be in good working condition. No sign of
hydraulic failure. Okay per BOH
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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
'GSM 70 Woodvale Lane
Property Address
Lisa Summers
Owner Owner's Name
information is required for every Centerville MA 02632 10/10/13
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
l
Commonwealth of Massachusetts
Title 5 Official .Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
70 Woodvale Lane
Property Address
.Lisa Summers
Owner Owner's-Name
information is . Centerville MA 02632 10/10/13
required for every
page. City/Towri _ 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
D .drawing attached separately
C.
01'0 0
a2-301
CL ,W
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 15 of 17
l
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
70 Woodvale Lane
M
Property Address
Lisa Summers
Owner Owner's Name
information is required for every Centerville MA 02632 10/10/13
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: $
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
checked with BOH agent
❑ Checked with local excavators, installers -(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
i
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
ti. W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
70 Woodvale Lane
Property Address
Lisa Summers
Owner Owner's Name
information is required for every Centerville MA 02632 10/10/13
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
I
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
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AsBuilt Page 1 of 1
TOWN OF BARNSTABLE
LOCATION 70 (x/ SEWAGE #
VILLAGE �v�rt ASSESSOR'S MAP&LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY CCU C� /� .�
LEACHING FACILITY: (type) O c>O �J —.(size)
NO.OF BEDROOMS Z--"
BUILDER OR OWNER r,�"j{y' r CEP Ad 6 004
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility _- Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet e hi fac' ' ) Feet
Furnished by
o C,
pr - C =may
http://issgl2/intranet/propdata/prebuilt.aspx?mappar=190182&seq=1 10/10/2013
TOWN OF BARNSTABLE
LOCATION -71) SEWAGE #
VILLAGE �� ASSESSOR'S MAP &LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY �� n �--
LEACHING FACILITY: (type) U Q K ✓�(size)
NO.OF BEDROOMS
BUILDER OR OWNER �i',�-�•c_ �P tX 014
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet ea hip fac)' ) Feet
Furnished by
13
��
t A Y
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address of property
Owner's name
Date of Inspection 3� �� 9✓�
I b PART A
CHECKLIST
Chec if the following have been done:
Pumping information was requested of the owner, occupant, and Board of
jeaHlth.
None of the system components have been pumped for at least two veeks
and the system has been receiving normal flow rates during that
period. Large volumes of water have not been introduced into the
system recently .or as part of this inspection.
As built plans have been obtained and examined. Note if they are not
available with N/A.
he facility or dwelling was inspected for signs of sewage back-up.
The site was inspected for signs of breakout.
11 system components, excluding the SAS, :have been located on the
site.
The septic tank manholes were uncovered, 'opened, and the interior of
the septic tank wass -inspected for condition of baffles or tees,
material of construction, dimensions, depth of liquid, depth of
l slLldge, depth of scum.
The size and location of the SAS on the site has been determined based
on ,existing information.. or approximated by non-intrusive' -methods.
The facility owner (and occupants, if different from owner) were
Y provided with information on the proper maintenance ,of SSDS. .
J'
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
If residential
{' 0--number of bedrooms
--L- rvumber of current residents
garbage grinder, yes or no
laundry connected to system, yes or no
seasonal use, yes or no
If . nonresidential, _ calcu ate f w:
Water meter readings, if available: j 9 ciL4 t��J 6-0C�
C-V PzAeN :-1,4 Last date of occupancy
GENERAL INFORMATION
Pumping records and sources information:
&j Ai eA /at J AJ
System pumped as .part of inspection, "yes or no _
if yes, volume pumped -
y
Reason for pumping: + -3
Type of system
Septic tank/distribution box/soil absorption system
Single cesspool ..
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection
records, if any) •
Other (explain)
Approximate age of all components. Date installed, if known. Source of
information:
Pi 7 r
/Ili Sewage odors detected when arriving at the site, yes or no
Zt
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORDS
PART B
SYSTEM INFORMATION continued
SOIL ABSORPTION SYSTEM (SAS) :
(locate on site plan, if possible; excavation not required, but may be
approximated by non-intrusive methods)
If not determined to be present, explain:
,
Type.
leaching pits and number
leaching chambers and number
leaching galleries and number
leaching trenches, number, length
leaching fields, number, dimensions
.overflow cesspool , number
Comments:
(note condition of soil , signs of hydraulic failure, level of ponding,
- condition of vegetation, r commendations for mainten n e o repairs,etc. )
CESSPOOLS locate on site plan) :
( P )
number and configur tion
depth-top of liquid t inlet invert
depth of solids layer,
depth of scum layer
dimensions of cesspool
materials of construction
indication of groundwater
- ._ inflow (cesspool mus pumped ,as
part of inspect '
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc. )
PRIVY:
(locate on site plan)
materials of construction
dimensions
depth of solids
Comments:
r ,n,
, (note condition of soil, signs of hydrauli failure,. level of ponding,
condition of vegetation, recommendations for aintenance or repairs,etc. )
•
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SEPTIC TANK:
(locate on site plan)
depth below grade:
material of construction: concrete metal FRP other(explain)
dimensions:
" sludge depth
� �
_ distance from top of sludge to bottom of outlet tee or baffle
_,!!:7 scum thickness
y distance from top of scum to top of outlet tee or baffle
_0 distance from bottom of scum to bottom of outleit- tee or baffle
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,
depth of liquid level in relation to outlet invert, structural integrity,
evince f Ieakk recommendations for repairs, etc. )
DISTRIBUTION BOX:
(locate on site plan)
depth of liquid level above outlet invert
Comments:
(note if .level and distribution is equal, evidence .of solids -carryover,
eviden a of�lekage into pr ou of bo ecommendation for repairs, etc
PUMP CHAMBER:
(locate -on site plan
pumps in working order, or no
Comments: -
_. . (note condition of pump chamber, condi of p s and appurtenances,
2._. recommendations for maintenance o epairs,etc. )
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE SPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100 '
f�;. 7 '5 -`51'
4
� L
_ter•—...,....�-y--_=�.�. ,»t. _•-}' .. - .,. .. ,;� _. ..-. .... ...« � ... _. ..«...-
DEPTH TO GROUNDWATER
,-
depth_�to ibundwater .� r =z': ZUa
r d
L � ,
2iod:tiof�deteri mination r<r:appr ation.`'� Y - m�:
A
*,c: E,,.. „�.,�. c :. •; ,f..kt.-,,p 0 a T-•-, y =° <, •a d fl; d':•-; cam.
!! __•.-.:,ram..:.,; t:-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C _
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of
determination in all instances. If "not determined" , explain why not)
� '�v Backup of sewage into facility?
U -v'Discharge or ponding of effluent to the sur ace- of the ground or
surface waters? O (j
Static liquid level in the distribution box above outlet invert?
Liquid depth in cesspool <6" below invert, or available volume< 1/2 de
flow?
Required pumping 4 times or more in the last year?
number of times pumped
05 Septic tank is metal? cracked? structurally unsound? substantial
infiltration? subs a tial exfiltrati=9 tank failure imminent?
00,
ADIs any portion of the SAS, cesspool" or p iv
below tlie, high roundwat r elevation'
A)() within 50 feet of a surface water?
IVO within 100 feet of a s rf ce water supply or tributary to a surface
water supply? Q '
within a Zone I of a public well? , /P
V
within 50 feet of a bordering vegetated wetland or marsh- . '
(cesspools and privies only, not the SAS)?_.. �- Y ,
4—/P within 50 feet of a private :water supply well?:.dGu�Ci r::Gt
p �T.._•s.. may....�. l 1'— 4 .a ,�y �:�:
_ LLless than 100 .feet but greater _than._50 �feet'-from a private water
_. _ _. _
supply. well with no acceptable_water quality analysis?__ If _the well
has been analyzed to be acceptable, attach copy of ^well water ane "
_for_ coliform bacteria, volatile org is com ds, ammonia nitrog
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CERTIFICATION
Name of Inspector
Company Name
Company Address
Certification Statement
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true, accurate and
complete as of the time of inspection. The inspection was performed and
any recommendations regarding upgrade, maintenance and repair are
consistent with my training and experience in the proper function and
manitenance of on-site sewage disposal systems.
Chec ne:
I have not found any information which indicates that the system fails
to adequately protect public health or the environment as defined in
310 CMR 15. 303 . Any failure criteria not evaluated are as stated in
the FAILURE CRITERIA section of this form.
I have determined that the system fails to 'protect public health and
the environment as defined in 310 CMR 15. 103 . The basis for this
determination is pr ' ed in the FAILURE 'CRITERIA section of this
form.
Inspector ' s Signature
Date
Original to system owner
Copies to: ,ri"e)
Buyer (if applicable)
Approving authority
r