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Home My WebLink About0091 HITCHING POST LANE - Health (2) 90 Hitching Post LaneNi m ; ' ! Centerville P 173 037 0 lllr .aFc�ccEo Z"rrtBtt�Q 11 1PC 12543 ., i 10 53LOR �iASTINGS,AM COMMONWEALTH OF MASSACHUS=S ExECUTIVE OFFICE OF ENVIR.ON'MEN'TAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED s VIAP �'ARCEh ; ® S E P 0 12004 ,vOT - TOWN OF BARNSTABLE TITLE 5 HEALTH DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: *Qo R t AtkV4 w Owner's Name: l Owner's Address Q ab3a Date of Inspection• O ( ,jL Name of Inspector:(pl a print) ram t✓ Lei Company Name: r`[ ✓tr * nS�aaKS Mailing Address: Telephone Number: — �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 the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority t Fails Inspector's Signature: Date: o a 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 now of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable;and the approving authority. Notes and Comments i ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I yi Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE IDISPOSAL'SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: �Tc Zoo — Owner- 9 f Z Date of Inspecti n• Inspection Summary: Check A,B,C D or P 1 ALWAYS complete all of Section D A. System Passes: 9, I have-not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass" on need to be replaced or repaired_The system,upon completion of the replacement or repair,as app by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the f wing statements.If"not determined"please explain. The septic tank is metal and over 20 years old*o e septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfihrzti or tank failure is imminent.System will pass inspection if the ,existing tank is replaced with a complying septic as approved by the Board of Health_ *A metal septic tank will pass inspection if it' y sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years is available. 1 ND explain: Observation of sewage b or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a oken,settled or uneven distribution box.System will pass inspection if(with approval of Board of Heal broken (s)an obstrm dm is Moved distribution box is IrMed or replaced ND explain: e system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system wild pass" on if(with approval of the Board.of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 r i Page 3 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner• Z Date of Inspection: O� 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 a 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 .303(1)(b)that the system is not functioning in a manner which will protect public health,safety a the environment: — Cesspool or privy is within 50 feet of a surface water — Cesspool or privy is within 50 feet of a bordering vegetated wetland o salt marsh 2. System will fail unless the Board of Health(and Public ater Supplier,if any)determines that the system is functioning in a manner that protects the publ' health,safety and environment- The The system has a septic tank and soil absorpt system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface w r supply. — The system has a septic tank and SA d the SAS is within a Zone I of a public water supply. The system has a septic tank an AS and the SAS is within 50 feet of a private water supply well. The system has a septic and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". ethod used to determine distance "This system passes if a well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile panic compounds indicates that the well is free from pollution from that facility and the presence of onia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria triggered.A copy of the analysis must be attached to this form_ 3. er: 3 Page 4 of.ll OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS _ SUBSURFACE SEWAGE DMA`SYSTEM INSPECTION FORM _ PART..A: CERTIFICATION(continued) Property Address: t,. Owner: Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _ x Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool of 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''/z day flow Required pumping more than 4 tames 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. aT Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface ' water supply_ _ Any portion of a cesspool or privy is within a Zone i of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet fi-om a private water supply well with no acceptable water quality analysis.-#This system passes if the well water..analysis, performed at a DEP certified taboratory;for caRfarm bacteria and volatile organic_compownds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equatto-or less thaw S ppm,Provided that no other failure criteria are triggered.A copy of the analysis mug be attached to this form.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure E. Large Systems: To be considered a large system the system mug serve a-facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the"following: ("The following criteria apply to large systems iuraiddition to the criteria above) s yes no fry _ the system is within 400 fee of a surface drinking water supply the system is within feet of a tributary to a surface drinking water supply the system is 1 ated in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of ublic water supply well If you have ans red"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in S • n D above the large system has failed.The owner or operator of any large system considered a signifi eat under Section E or failed under Section D shall upgrade the system in accordance with 310 CUR 15.3 a system owner should contact the appropriate regional office of the Department. 4 r Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: c /t t r Owner: Date of Inspection• O� Check if the following have been done You mast 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? y _ Were as built plans of the system obtained and examined?(If they were not available note as NIA) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? _ Were all system components,excluding the SAS,located on site? _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition oflthe 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 iLnte_nance of subsurface sewage disposal systems?, The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no c _ Existing information_For example,a plan at the Board of Health. sT Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of distance Tunac_ceptable)[310 CMR 15.302(3)(b)] 5 Page 6 of I I OFFICIAL INSPFCTIUN FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: !7 Owner- R.0 t 01 _ Date of Inspection: /4 O FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system_(yes or no):` [if yes separate inspection required] Laundry system inspected(yes or no):ACL' Seasonal use:(yes or no):ko 01 Water meter readings,if available qqst 2 years usage(gpd)): I O Sump pump(yes or no):ftcm—lv— COMMERCIALANDUSTRIAL Last date of occupancy: Type of establishment: Design flow(based on 310 CMR 15.203):,---f' gpd Basis of design flow(seats/persons/s etc.): Grease trap present(yes or no): Industrial waste holding resent(yes or no):— Non-sanitary waste disc ged to the Title 5 system(yes or no):— Water meter reading,tf available: Last date of occu cy/use: OTHER scribe): GENERAL INFORMATION Pumping Records (� Source of information: P—t Cse 4— 4 Was system pumped as part of the inspection(yes or 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) Tight tank _Attach a copy of the DEP approval _Other(describe): 7 Approximate age of all fom nen date installed ' known)and source of information: Were sewage odors detected when arriving at the site(yes or no): 6 Page 7 of l 1 OFFICIAL: INSPECTION FORM-NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 7b iTGGtI G� 7- - Owner: �--�- Rate of Inspection: 1 t U OU BUILDING SEWER(locate on site.plan) . Depth below grade: c� Materials of construction:—cast iron Y 40 PVC_other(explain): Distance from private water supply well or suction Iine: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: V (locate on site plan) c Depth below grade: Material of construction: k concrete_metal_fiberglass___polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):`(attach a copy of certificate) / Dimensions: lb00 4,al Sludge depth:.(2c' Distance from top ofsludge to bottom of outlet tee or baffle: _o- Scum thickness: _ Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee baffle:1_7 How were dimensions determined: ,MeA sure Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage, c.): tl GREASE TRAP:_(locate on site'plan) Depth below grade:— Material of construction:_concrete_meta _fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to t of outlet tee or baffle: Distance from bottom of sc to bottom of outlet tee or baffle: Date of last pumping: Comments(on pump' recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet' vert,evidence of leakage,etc.): 7 Page 8ofil OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS T SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C // SYSTEM INFORMATION(continued) Property Address: c �l% f►d��! r Owner: Date of Inspection: 8 71 TIGHT or HOLDING TANK: (tank must be pumped a of inspection)(locate on site plan) Depth below grade: Material of construction: concrete me fiberglass_polyethylene bther(explam): Dimensions: Capacity: Design Flow: ons/day Alarm present(yes or no): Alarm level: in working order(yes or no): Date of last pumping: Comments(con ' ' of alarm and float switches,etc.): (DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:AI Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage, r o t of bo etc.): rLu�f El. TsC�7 rt�Gv"! �j,DSI�idl C7"�!" C�-�lkCs , PUMP CHAMBER: (locate on site ) Pumps-in working order(yes or Alarms in working order(ye or no}: Comments(note conditi of pump chamber,condition of pumps and appurtenances,etc,): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFAC]f SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) / p Property Address: D ! r�0- P6 Y kata _ ¢ Owner.�, A" "Z.. Date of Inspection: l� SOIL ABSORPTION SYSTEM(SAS):_JL(locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number_ leaching chambers,number. leaching galleries,number- leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number. innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): t I S kQ T t c� )5 avo 0arc a :h CESSPOOLS: (cesspool must be pumped as part of' to (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 es or no): Comments(note condition of tl,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 conditio f soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address 0 t ✓t P6,<4 Owner: Date of inspection- Lo SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. 36 �n Page 11 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: q0 u D i Owner Date of Inspection: SITE EXAM Slope YQS Surface water Check cellar Shallow wells Y.30 Estimated depth to ground water 4d�eet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must d cribe how you established a high ground wate eleva ' n:��ss y m �• V� � e�Ucl 11 ov- LOC T ION � S E WAGE PER T NO. VILLAGE INMSTINST LE 'S NA E i ADDRESS L E OR OWNER DATE sPERMIT ISSUED DAT E COMPLIANCE ISSUED r 97