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HomeMy WebLinkAbout0027 HARBOR HILLS ROAD - Health 27 HARBOR HILL RD. CENTERVILLE A - � J A 'I UPC 12534 No.2„ 15_3_L OR �o HAi11N06,VN r s• Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 27 HARBOR HILLS RD Property Address LEWENTAL r •� Owner Owner's Name " information is ENTERVILLE MA 02632 8-5-15 ` required for C •r•:. every page. CitylTown State Zip Code Date of Inspection I: Inspection results must be submitted on this form. Inspection forms may not be altered in any --j way. Please see completeness checklist at the end of the form. Important: When filling out A. General Information �/ forms on the ////Z computer, use 1. Inspector: only the tab key to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return key. D.A.BROWN INC Company Name ffi P.O. BOX 145 Company Address CENTERVILLE MA 02632 City/Town State Zip Code 508-420-4534 S14297 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 ❑ Needs Further Evaluation by the Local Approving Authority 8-5-15 Inspe s Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes condit4l�s 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts , Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 27 HARBOR HILLS RD Property Address LEWENTAL Owner Owner's Name information is required for CENTERVILLE MA 02632 8-5-15 every page. Cityrrown 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: TANK IS PARTIALLY UNDER DECK. THE DECK C SONO TUBES DO NOT APPEAR TO BE RESTING ON THE TANK. SYSTEM IS FROM 1983 HOUSE IS ONLY OCCUPIED PART TIME . FUTURE PERFORMANCE UNDER THE SAME OR INCREASED USE CAN NOT BE DETERMINED FROM THIS REPORT. 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 2 0 ears old or the e septic tank whether metal or not is Y P ( ) 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-3/13 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 M ,.•°°< 27 HARBOR HILLS RD Property Address LEWENTAL Owner Owner's Name information is required for CENTERVILLE MA 02632 8-5-15 every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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•3113 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 27 HARBOR HILLS RD Property Address LEWENTAL Owner Owner's Name information is required for CENTERVILLE MA 02632 8-5-15 every page. Cityrrown 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 %day flow t5ins•3113 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 M �'< 27 HARBOR HILLS RD Property Address LEWENTAL Owner Owner's Name information is required for CENTERVILLE MA 02632 8-5-15 every 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 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, 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-3113 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 27 HARBOR HILLS RD Property Address LEWENTAL Owner Owner's Name information is required for CENTERVILLE MA 02632 8-5-15 every page. CitylTown 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? ❑ ® 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? ❑ ® 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): 3 Number of bedrooms(actual): 2per assessing DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of V i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 27 HARBOR HILLS RD Property Address LEWENTAL Owner Owner's Name information is required for CENTERVILLE MA 02632 8-5-15 every page. City/Town State Zip Code Date of Inspection D. System Information Description: A 1000 gallon tank d-box and leach pit are shown on the as-built card Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ❑ No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: minimum water usage, system not designed for garbage grinder Sump pump? ❑ Yes ❑ No Last date of occupancy: seasonalDate 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-3113 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 , 27 HARBOR HILLS RD Property Address LEWENTAL Owner Owner's Name information is required for CENTERVILLE MA 02632 8-5-15 every page. Cityfrown 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: debarros septic Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? Reason for pumping: maintenance Type of Y S stem• ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 .� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,•''y 27 HARBOR HILLS RD Property Address LEWENTAL Owner Owner's Name information is required for CENTERVILLE MA 02632 8-5-15 every 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: 1983 per as-built Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 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: 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 gallon Sludge depth: moderate t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 27 HARBOR HILLS RD Property Address LEWENTAL Owner Owner's Name information is required for CENTERVILLE MA 02632 8-5-15 every 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 Scum thickness moderate Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 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.): tank was pumped at time of inspection for maintenance and was found to be in working order. the tank is partially under the deck but the sono tubes appeared to be just outside of the ends of the tank 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 27 HARBOR HILLS RD Property Address LEWENTAL Owner Owner's Name information is required for CENTERVILLE MA 02632 8-5-15 every page. Cityfrown 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 Lt5ins3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 27 HARBOR HILLS RD Property Address LEWENTAL Owner . Owner's Name information is required for CENTERVILLE MA 02632 8-5-15 every page. Cityrrown 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 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 27 HARBOR HILLS RD Property Address LEWENTAL Owner Owners Name information is required for CENTERVILLE MA 02632 8-5-15 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Pit was opened and had about 2 ft of water at time of inspection with no signs of failure . Future performance under the same or increased use can not be determined from this report. System appers to be original and property is only occupied seasonally 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•3/13 Title 5 Official Inspection Forth: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 27 HARBOR HILLS RD Property Address LEWENTAL Owner Owner's Name information is required for CENTERVILLE MA 02632 8-5-15 ' every page. Citylrown 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 vegr®fatioh, etc.): t5ins•3/13 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 °y< 27 HARBOR HILLS RD Property Address LEWENTAL Owner Owner's Name information is required for CENTERVILLE MA 02632 8-5-15 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts „ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments k5 i"p-ow 27 HARBOR HILLS RD Property Address LEWENTAL Owner Owners Name information is required for CENTERVILLE MA 02632 8-5-15 every page. CitylTown 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: at least 4 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: attached 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: design plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 i Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 27 HARBOR HILLS RD Property Address LEWENTAL Owner Owner's Name information is required for CENTERVILLE MA 02632 8-5-15 every page. Cityfrown 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENmoNMENT ^FAI 3 DEPARTMENT OF ENmONMENTAL PR CTIOfry` ONE WINTER STREET,BOSTON MA 02108 (617)29 0 SFP CO 1999 tR,DY COXE Secretary A ARGEO PAUL CELLUCCI D B. STRUHS Governor �' 'ji Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address:a l t-Agrbcr Hi tl S Qd. Name of Owner w t.s T �11 °t^�s pG�Y: Address of Owner: a n-%f Dete of Inspection: y-a3-99 _ Name of Inspector:(Please Print) SAtr.!L Rissnnmtrrs 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: Inc. MailingAdd►ess: P.0• 0" yiq I-Akr;"'L b1a_ eaS,17_ Telephone Number: _Se8-9y7.7735 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Inspector's Signa Date: S-�3-99 The System Inspector shall submit ction report to the Approving Authority(Board of Health or DEP)within thirty(30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable, and the approving authority. NOTES AND COMMENTS,ils �re-. a c y of this inspe )tN E_ Sjs4cin wnS +lc+ viclai�..C� qr,y �(rR;1orti cL:,fie: ,cam Cx+ �1ML V InifJtC}t611 -1�£ v-,n.ta( k^b\z. WC.S { F�VCE f1 tfor.rl 1 �E Cie etc% Irn eve_\ h keex- p�1 Straws jE CL CQ ��s_ sys�F 1 TtIc�L p�1iY10. p( (J cti revised 9/2/98 Page Iof11 h ;� Printed on Recycled Paper � I r 'a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: :l H 9r DGc H�i1 s Vj. Owner: L;s.i Gcu!j Data of Inspection: .S-33 iri INSPECTION SUMMARY: Check A, B, C, or A A. SYSTEM PASSES: �/LS_ 1 have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure —� criteria not evaluated are indicated below. COMMENTS: NCT :j tGt..-AT%uto A644 FRI LL;'—S Ccil i-t �e, c*a tv\F CC 1115_PECtiAft B. SYSTEM CONDITIONALLY PASSES: NO One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement'or repair,as approved by the Board of Health, will pass. Indicate yes, no, or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined", explain why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20) years prior to the date of the inspection; or the septic tank, whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed T revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:X1 M ortm c- Wit-5 Rd. Owner: Gr,,E;r Date of Inspection: -33 -•jq ' C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:. Q CG Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1Hb)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50-feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 Page 3or11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:a7 H n b c r V11►i s Va. Owner:G;e;,;i Date of Inspection: D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: 9 N o I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: 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: NC The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area=1WPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system In accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4ofII i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST i Property Address:')'I %-1 a c be c- 0,115 Owner: C:c e e%-, Date of Inspection: Y-a 3 1 q Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No _ Pumping information was provided by the owner, occupant, or Board of Health. � ' _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. f _ As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. ✓ _ All system components,excluding the Soil Absorption System, have been located on the site. ✓ _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: f _ Existing information. For example, Plan at B.O.H. _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) (15.302(3)(b)] _ The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Addres r c r H 15 e Owner: Date of hapecdon: -jr-3 3 •-19 FLOW CONDITIONS RESIDENTIAL: Design flow: I L Q g.p.d./bedroom. Number of bedrooms(design): Number of bedrooms factual): Total DESIGN flow Number of current residents:_J_ Garbage grinder(yes or no):_Zj!: Laundry(separate system) (yes or no):L^: If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use(yes or no): NO Water meter readings,if available (last two year's usage(gpd): Sump Pump(yes or no):-hiv Last date of occupancy: S+,1 I COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: sad ( Based on 15.203) Basis of design flow Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no► Non-sanitary waste discharged to the Title 5 system: (yes or no►_ Water meter readings,if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection:(yes or no),b� If yes,volume pumped: gallons Reason for pumping: TYPE OF SYSTEM P K Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known)and source of information: lal g (�z�' {�.U• K - Sewage odors detected when arriving at the site: (yes or no) revised 9/2/98 Page 6of11 7 u, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:al R arbot N"ws ed. Owner:Grerh Date of Inspection: S- 43-ti9 BUILDING SEWER: (Locate on site plan) Depth below grade:_ Material of construction:_cast iron_40 PVC_other(explain) Distance from private water supply well or suction line Diameter Comments:(condition of joints,venting, evidence of leakage,etc.) SEPTIC TANK:A (locate on site plan) Depth below grade: 1 , Material of construction:_jLconcrete_motel_Fiberglass _Polyethylene_other(explain) If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions: K S K 5 Sludge depth: I it Distance from top of sludge to bottom of outlet tee or baffle: to Scum thickness: D"—t" Distance from top of scum to top of outlet tee or baffle: �3 Distance from bottom of scum to bottom of outlet tee or baffle: ► 3 � How dimensions were determined: Ms-ASvN't Vct..i Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) we '5 11.1 c-, ('A tg. cI c r, GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_metal_Fiberglass _Polyethylene other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) revised 9/2/98 Page 7of11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:,)-) H n r nu.- H i t t s ed. Owner:Gi-e-en Date of Inspection: j- 3 a q TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(explein) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present _ Alarm level: Alarm in working order:Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: 0 Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER:_ (locate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) revised 9/2/98 P2ge8Of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Aroperty Address: a7 N A Or N,r 2d. Owner: G;e e n Date of Inspection:g-a 3.Ljq SOIL ABSORPTION SYSTEM(SAS) (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number:_I leaching chambers,number:_ leaching galleries,number:_ leaching trenches,number, length: leaching fields, number, dimensions: overflow cesspool,number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure,level of ponding, damp soil, condition of vegetation, etc.) Nr SiQn .CH.1 ,c'> Q4-I I CI In CESSPOOLS-_ (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: lepth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.) PRIVY:_ (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) revised 9/2/98 Page 9orii SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 7l 41q�oc; �1:us Qd . Owner: re z r\ Date of Inspection: 4_ 3 SKETCH OF SEWAGE DISPOSAL SYSTEM: icue h cote all wells within 100' (Loc a where public water supply comes into house) 27 A B '� O O A-1-18'6" A-2-36' A-3-29' A-4-35' B-1-41'6" B-2-36'6" B-3-31' 2 B-4-24'6" NOT TO SCALE revised 9/2/98 Page 10of11 n SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) *operty Address: cl-) H A r h(;c- NMS Owner: G r e e n Date of Inspection: NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater 13 Feet Please indicate all the methods used to determine High Groundwater Elevation: Y Obtained from Design Plans on record Observed Site(Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health _Checked FEMA Maps Checked pumping records Checked local excavators,installers Used USGS Data Describe,how you established the High Groundwater Elevation. (Must be completed) O�CGvnd W0AE Cf � C1Ccv►1� 10� revised 9/2/98 Page 11of11 LOCATION (+Q SEWAGE PERMIT NO. .� 2 �,�.►.-boy y/� /P� VILLAGE INSTA LLER'S NAME i ADDRESS To4� A: Auld /'Vi /•/A/'!9 3!s�J' /•I B U I L D E R OR OWNLERn Ll c/T 1,2,eAh rq GATE PERMIT ISSUED - 30 - p DATE COMPLIANCE ISSUED 41 bol . u Vol' �. COMMONWEALTH OF MASSACHUSETTS n EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAI q61, DEPARTMENT OF ENVIRONMENTAL PROTE ON logy r S �< ONE WINTER STREET. BOSTON. MA 02108 617-292-5500 yq�gg9NS 199� WILLIAM F.WELD 1 r, TRUDY Q XE Governor •`Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION C'@ lu' ,Vl &- Property Address. 27 Harbor Hills Rd, �t �r s of Owner: David Hartnett Date of Inspection: S 42 (If different) 597 Eagles Nest Name of Inspector: WM E Robinson Sr Plant City, FL 33565 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: �Im E Robinson Septic Service Mailing Address: PO Box 1 089, Centervi 1 1 e r MA 02632 Telephone Numbers S 0 AY 7 7 5-$7 7 6 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site,ypas ge disposal systems. The system: _4 ses _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: d — Date: N The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION,SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate es, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web: http://www.magnet.state.ma.us/dep 0 Printed on Recycled Paper 4 t. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 27 Harbor Hills Rd, W Hyannisport Owner: David Hartnett Date of Inspection: Q I `al-^4 - B] SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] FU HER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: I h in order to determine if the system is failing to protect the h and of Heat Y g onditions exist which require further evaluation by the Bo ublic health, safety and the environment. 1) YSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER HICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 PP m. Method used to determine distance (approximation not valid). 3) THER (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 27 Harbor Hills Rd, W Hyannisport Owner: David Hartnett Date of Inspection:,`��� /7 D) SYSTEM FAILS: ou must indicate ei;!,er "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. _ Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LAR E SYSTEM FAILS: You mu indicate either "Yes" or "No" as to each of the following: he following criteria apply to large systems in addition to the criteria above: he system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to ublic health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area- IWPA) or a mapped Zone II of a public water supply well) The ow r or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program require ents of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 27 Harbor Hills Rd, W Hyannisport Owner: David Hartnett Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No _ Pumping information was provided by the owner, occupant, or Board of Health. y _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. *S _ The facility or dwelling was inspected for signs of sewage back-up. f _ The system does not receive non-sanitary or industrial waste flow. f _ The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. •5 _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. _ Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)) (revised 04/25/97) Page 4 of 10 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 27 Harbor Hills Rd, W Hyannisport Owner: Davi arnett Date of Inspection: �—11.��1 FLOW CONDITIONS RESIDENTIAL: Design flow: D g.p.d./bedroom for S.A.S. Number of bedrooms: Number of current residents: Garbage grinder (yes or no):—?-- b Laundry connected to system (yes or no)y.!�-J Seasonal use (yes or no): z'3 Water meter readings, if available (last two (2) year usage (gpd): 1 9 9 5 — 5 7 , 0 0 0 g Sump Pump (yes or no):_Ae O 1996 — 1 1 5, 0 0 0 g Last date of occupancy: g7 COM RCIAUINDUSTRIAL: Type of tablishment: lo Design f :_gallons/day Grease tra present: (yes or no)_ Industrial Vaste Holding Tank present: (yes or no)_ Non-sanitafy waste discharged to the Title 5 system: (yes or no)_ Water me er readings, if available: Last d of occupancy: OTHE : (Describe) Last d ccupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Syste pumped as part of inspection: (yes or no).d If yes, volume pumped: Qallons Reason for pumping: TYPE ESTTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information:/,z Sewage odors detected when arriving at the site: (yes or noko (revised 04/25/97) Page 5 of 10 T SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 27 Harbor Hills Rd, W Hyannisport Owner: David Hartnett Date of Inspection: 5• 1 BUILDING SEW R: (Locate on site plan) , e Depth below grade: Material of construct o =cast iron _40 PVC _other (explain) Distance from privat ater supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: (locate on site plan) Depth below grade: Material of constru ion: oncrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: 4 a 1 Sludge depth: 3 —S a Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: /-36 , Distance from top of scum to top of outlet tee or baffle: , from bottom of scum to bottom of outlet tee or affle: Distance � How dimensions were determined: Q �i�— ®t✓Ld i2 3/J��'9 ��d�p `� Comments: (recommendation for pumping, condition of inlet an outlet tees or baffles, depth of liquid level. n,relation to outlet invert, structural integrity, evidence of leaks etc.) 4 e $ Tyi�� �` '�`y 9 GREAS TRAP: (locate n site plan) Depth ow grade: Material f construction: —concrete. _metal _Fiberglass _Polyethylene —other(explain) Dimensi s: Scum thi kness: Distanc from top of scum to top of outlet tee or baffle: Distan from bottom of scum to bottom of outlet tee or baffle: Date o pumping: Comments: (recomme ation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, vidence of leakage, etc.) Ia (revised 04/25/97) Page 6 of 10 f I -v SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 27 Harbor Hills Rd, W Hyannisport Owner: David Hartnett Date of Inspection: T/oL-1 ? TI TOR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (locate n site plan) Depth be ow grade: Material f construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dime ions: Capaci gallons Design low: gallons/day Alarm I vel: Alarm in working order _Yes; _ No Date of previous pumping: Com nts: (cond' ion of inlet tee, condition of alarm and float switches, 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, evidence of leakage into or out of box, etc.) 6 PUMP AMBER:_ (locate o site plan) Pumps in orking order: (Yes or No) Alarms in working order (Yes or No) Commen s (note con ' ion of pump chamber, condition of pumps and appurtenances, etc.) (reviaad 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 27 Harbor Hills Rd, W Hyannisport Owner: David Hartnett . Date of Inspection: Fes-/�7-.. Q- SOIL ABSORPTION SYSTEM (SAS):v (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level, pond ng,-condition f etation, c.) ./ c d S CES OOLS: _ (locat on site plan) Numbe and configuration: Depth-t p of liquid to inlet invert: Depth o solids layer: Depth o scum layer: Dimensi ns of cesspool: Material of construction: Indicatii of groundwater: inflow (cesspool must be pumped as part of inspection) Com nts: (note co ition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:_ (locate on si a plan) Materials o construction: Dimensions: Depth of s lids: Commen : (note co i ion of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Page 8 of 10 PAGE 0 a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 27 Harbor Hils Rd, W Hyannisport owner David Hartnett Daft of Inspection: 7 5011 ABWRPTION SYSTEM(SAS):V ilucale on site plan, if possible; excavation not required, but may be approximated by non intrusive methods) If not determined to be present,explain: Type: leaching pits, number:, leaching chambers, number leaching galleries, number; lexhing trenches, number,length: leaching field;, number, dimensions' overflow cesspool,number: Alternative system; Name of Technology: Com►nents: (note condition of soil, signs of hydraulic (allure, level of ppnndde2j condition of vegetation, etc.) —zo,s a Q A :..& D.. t ref -+ Fie4 �e�.� ,e F b l s CE CI,5:_ II= on site plan) Num and configuration: Dwh- of liquid to inlet invert: Depth I Wilds layer: Depth f'sEum layer: Di ions of cesspool: Matei is of construction: Indica on of groundwater: inflow(cesspool must be pumped as part of inspection) Co (note c indition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.) UtJ''al On site plan? Meter, of construction: Dimensions: Depth o salfds• Ce►rei�te is (note c ition of soil, signs of hydraulic failure, level of pending, condition of vegetation, etc.) Lem— {errssN W/ss/sit a.y. s me 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 27 Harbor Hills Rd, W Hyannisport Owner: David Hartnett Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) l°�r i V 3n (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 27 Harbor Hills Rd, W Hyannisport Owner: David HarXtnett Date of Inspection:,? tom_q Depth to GroundwaterIvAl Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record t//Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your owgn�words how you established the High Groundwater Elevation. (Must be completed) (revised 04/25/97) Pago 10 of 10 r PAGE.' 05 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC11p,y FORM PART C SYSTEM INFORMATION (Continued, Property Addrecsr 27 Harbor Hills Rd, by Hyannisport Owner: David Hartnett Date of lavection; ��'7•.-P ry Depth to Gtoundwater� feet Please indicate all the Methods used to determine high Groundwater Elevation. . �. Obtained Gom Design Plans on record �Obsetvatton ar Site(Abuttingre property, observation We, basement sump etc,) Determine it Irom local conditions Check with local Board of health _„,_CMct FWA Maps Check pumpint records Check local excavators, installer Use USGS Data Dexribc in your o,.+,t words how you established rho I-I�I CSrndwalQ Elevation. t`Z„•cornp'ci.ect} is..ta.a artttsisr�; �•fts 10 of IQ I-J 4... CAMPBELL RE PAGE 0b LOT l LOT 47 it Ilk LOT 46 r � LOT rrJr :,r; - O `Y.�� !/ /.7�4 ,'r:rrr rJrrr t J Cp /rr,!'o rrr/rr J rrr rr//rr h on t { N�34�9' \'7 R 71 70 NOTE. THE PLAN OF VfE LOT DCD NOT CLOSE' 'eS 2oNE :4g1" --- This MORTGAGE INSPECTION �? n 7�1 L � �� ' PI3r, 13 Foi' £L�vlr Gl./!��['r.� �t., iG ti REGIETR 0 IVER: _0_41.1Z �: � DEED REF: - — -- — - BUYER: _.E'L)ZJS�'?Ya� DATE: �? � , — — — & BF - T 5� '— _ — — PLAN REF'. 12� — — - H R I3Y GE C F'Y TO i — — SCAr 17�= 1- - ---CL ------.-THAT THE BUILDING ��Sti5WN ON THIS PLAN ISTLOCA`I'EI) CAN THE GROUND AS a� YANKFE EllvE1 SHOWN AND THAT ITS POSITION DUES _ CONFORM � rALkA, �,� CJNS U LTAINTS TO HE ZONING LAW SETBACK REQUfREMENTS OF T14E $ WAFTHew = 40 (SL'ITF, 1) j TOWN S 11( 2,Q��__ ----- AND THAT No,3�$ `� INDUSTRY ROAD :T DOES_�YCI LIE WITHIN THE SPECIAL FLOOD 14AZARD �� MARSTONS M.I.LS, MA. 0Z646 RREA AS SHOWN 4N THE H.U.Il. MAP DATED_ ! �. a�N C7D01 �N Eb^,, 2s—UUSta r1�...s4�_ .� f EL: 4 �" D 08 0.. THIS rLAN NOT hfADE FRO►.(, AN ] „ RUMENT FAX. 420-•555, SVRV-Y NOT 70 BEUSED C`OR FENCES �'rc. 21�9�a ��'fj V V V No.....�3...... 7`L- Fss........ .............. THE BOARD COMMONWEALTH� FH EAL USETTS � I-4��, b R ��j,�� ,,_/' A' �.. .............OF......./ !'tt. V�----------------.............................. `W -gWAppliratiun for Uiipuiittl Worko Tunitrurtiun Vrrmit Application is hereby made for Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: cat, - --res - -----•- ..................... .... ........................... ow O r d s �-� a .............. :... .-.-----...._.................--.-- __--______•-------.-• _ Installer Address dType of Building Size Lot______________�.....Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixt�ye W Design Flow____________________________________________ gallons per person per day. Total daily flow.......... Z..0__..._.__.__...._.gallons. Od Septic Tank—Liquid capacit/gallons Length................ Width................ Diameter................ Depth................ W Disposal Trench—No ____________________ Width_____..._.-.____._ Total Length.___.___.__.__..._.. Total leaching area.................... ft. x //..__.___ Depth below inlet..___........... Total leaching area..`12_f sq. ft. Seepage Pit No--------/--,-______. Diameter...__. Z Other Distribution box ( ) Dosing��nk ,[ Percolation Test Results Performed by.. !G� ......... ��'wl �/9 .......................•--•- -=..._..._..._. Date.--------•----- --------------•-•--- aTest Pit No. 1._...Z..._._minutes per inch Depth of Test Pit..... . Depth to ground water........................ Test Pit No. 2......._________minutes per inch Depth of Test Pit.................... Depth to ground water........................ ----:_.._.. .....�. -------•----- ------------ -- O Description of Soil -4' �,-•-•----.......-•---...----•a-• =`.---- �— .tsv �✓ x f� i, ---' _`__J.. W --- ---------------..................................................................................................................................................................................... UNature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________ .........................................................._-•-•--•-•-•-•---•--••---•...........................----------------••••---••-•-._.......--••-•••-•--•••--•••---•-••._...__......_........_. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitagbei The un signe urther agrees notto place the system n operation until a Certificate of Compliance has by h and Signed- ----------- ---------•-•-•- ._...... ................... .......R ,.® Date Application Approved By............ ...--•..:..... ..........:.....•_---• ..._._.....__..7......................3°-�3 - ..............•--..._................... Date Application Disapproved for the following reasons:......................................................................_-....................................... ... Date PermitNo.... 3- `Z ............................ Issued-.................................................... Date No.....73.......°�.7`l'' FE$...... �. THE COMMONWEALTH OF MASSACHUSETTS BOARD F- HEAD 1 1p ��Q ° OF......................................................... , rpfiratiun for Mivaal Workri Tonvuurtion Frrmit Application is, hereby made for Permit to Construct, �orepair ( ) an Individual Sewage Disposal System at: ................. ... 1` l, ..�-•--- --------------•----•------••---___----- ( ------- �J ...........................I ` ` ......... .... •--- t W •---._.- ....................... r- •-•-------------••=•-_._ ................................................��.�...-, . ...... Installer Address UType of Building Expansion Attic Size Lot___`___.______ ,.___Sq. feet Dwelling—No. of Bedrooms__________ p ( ) Garbage Grinder ( ) � Other—Type- of Building ____________________________ No. of ersons__.___.__.____._____________ Showers LLIg P ( ) — Cafeteria a' Other fixt d --------•--•----------•----------------------------------------------•--_-__--• ....__........._......---.....----_--••- W Design Flow............................................gallons per person per day. Total daily flow..........Z.........................gallons. WSeptic Tank—Liquid capacit/ allons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No_____________________ Width____a_._.._........ Total Length.................... Total leaching area......._____..___ sq. ft. Seepage Pit No._._.._.�- _______ Diameter...... Depth below inlet_____._.......... Total leaching-area... sq. ft. Z Other Distribution box ( ) Dosing nk Percolation Test Results Performed by...fK'_..._. w'(. Date.......69j Test Pit No. 1...... ......minutes per inch Depth of Test Pit_____ ____________ Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...._................... Q+' _ ............................................. Description of Soil.... .�-•- - --------•-•-•--•-- U --------•.. .._...-----6•i�-l3-1-•--•-4� c--'�f'� ��N-----=''�- 't"""_ ____________________ _____•-------..._..._. W VNature of Repairs or Alterations—Answer when applicable--------------------------------------•........................................................ ...... .. ................................................................•--•--...._. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T IT LE 5 of the State Sanitary Code The un ;signe ` urther agrees not to place the s stem;tn operation until a Certificate of Compliance has been i ed by h and frliea Signed... ........... .......... ................ ....... ................... � D to ApplicationApproved By......1 - ............i-------•-•---•-•.............•-•------------._..._............... 7.:__` ".. .3...... Date Application Disapproved for the following reasons-----------------------•----••----•-••---...------...---------•-••--•-----------__••-•---•-::..-•------=•--•---•- _...._•---•-•••----------••-•-•-------------•--_....-••-•-----_._..---•----------•----...--------•-------•---...........--••---•-••------------.-..--------------_..._..__....--•-_.....__.......-- �9 3 ? Date PermitNo......................................................... Issued................................................. Date /THE COMMONWEALTH OF MASSACHUSETTS / BOARD OF HEA T Trrtif iratr of Tomptiatta THIS IS TO CE�,'C•�Y,, That th ndiv' ale : e Disposal System constructed t( or Repaired ( ) by ,�. (n _-__---- _... ... f Ins ll at. d�(o------. ....---D�: /l1_•.._..-ew.-----------=-------- = = has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the- application for Disposal Works Construction Permit No......................................... dated................................................ THE ISSUANr.E OF THIS CERTIFICATE SHALL NOT BE CONS E® AS A GUARANTEE THAT THE SYSTEM �llll I CTION SATISFACTORY. DATE_10.✓................•---.......----..__....._..----------•----•---•---. Inspector... ... --•---------------•-------------•---------•------------------•----------- THE COMMONWEALTH OF MASSACHUSETTS BOARD HEAL,,ITry I OF...--.- ----. �''�...}..�_....(�....(.�............................... 1XJ No....... - FEE........................ Permissionis eby granted -------------••---....------_•-.---�-----•-•--------•-----•----•---•--•._..._.-_....'-` .._..----..._..........._.... to Construct or pair ( ) an xtividual Sley�a ispos stem at No. f ��- �D !</!.1 1�-U.-= -: ............................. ............... Street f�' as shown on the application for Disposal Works Construction Permit No.._ .l�- = 7 A ev-_3©:- -.3-_-- ..-•-----••- Board of•Health DATE...............I"-------------------•------••--•------••--------------••--- FORM 1255 A- M- SULKIN, INC., BOSTON , i ►► c- FAMIt_Y - BC0QOOM �" G� 'o G'A IZ BA G E 6 Qj NJ D 6 ' P G p Ib 04- r7 n Flow _ IIU X 3 = o Iv0 •vv �I rjEPT1G TP1.1K = 330x15o% = .49% 6.P. Q Jos' , V5E- 1Ooo GAL. ,� /0 W-+ -4 :I 0 o►5Po5n� PIT V5E I 5%r)r-Y/ALL. A2CA = ►�o s.t BOTTOM AQE.A PIT �I -ToTA CI.PD. j PE2�oL-ATIoN RATE I'�tN 2M1�1 D�LE55 ; 2D 4�� OF Ate Imo•o n .;/rFtICHARD o ALA c l J, A. a W. �, DAXTER o JONES Plo.240480 ca 0,0100 Q/STSR� Np St14`I `01YAIL �I T6`5T TOP FNU = 100.0 t�oLF l>-9-$3 =Ica II ^ ' loov INS• S(JB�i�I(� D I ST. 'I N�.• Gal.. Q7.8' 2 Ou�C �OA 9PTIG ►000 IWV .., TANK SAI �.0 rr li(=A BC.► PIT i N V. I N Y. WIT41 L I'�3/q•I VL WASuGD 5'ru N E OADW QI•o GE2TiptCD PLOT PI-A►-I PRUPIL� L0CA7I011-J AT 8�2�IB3 WAVTZ-.o' :I p A r� REF raze N C,a I 2EoN COMPI-`(5 1rJ TNaNE S oELIN ��N -dT 41— AE CID SE'c�GK 26Qu1R-EMENT� o -tµ>= -To W N O -IaA 24J�7k3(Z A N'D le., NOT -r- LOGp.TED 'WITNI TN Gl-OoD PL_ IN I�- IU3 `P(o• I2'� Do.TE�'�-3 � t,� �� AxTE2e h.l`{E INC• B -T INS P L.6,N ► 5 N aT c3 5 c n o►d A tJ a 5-r E sz v I L.L.� - MPS S lu'5TR.VMENT SU2Vey -TNA �1-t=,5ET5 5uau� N;oT p� 'USEDTO �ETERf^Ir1E t_.oT - INE�j APPLICA►`1 T1�A1� �.C LOCATION y� SEWAGE PERMIT NO. VILLAGE INSTALLER'S NAME & ADDRESS B U I L D E R OR OWNER DATE PERMIT ISSUED _ 3p -$7 PAT E COMPLIANCE ISSUED r Clio zs ,� LOCATION S E W A E PERMIT NO. - 7 PILLAGE Ic7 INSTA LLER'S NAME i ADDRESS Tod h A Ru/f 0 U I l D E R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 9� CIA