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HomeMy WebLinkAbout0032 BLUEBERRY HILL ROAD - Health 32 Blueberry Hill Road Hyannis ,A= 249—067 o - i i ' Commonwealth of Massachusetts �'�7�9 D 60 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v� 32 BLUEBERRY HILL RD Property Address JOSEPH HAYES-524 OLD BARNSTABLE RD E FALMOVTH MA 02536 Owner Owner's Name / information is HYANNIS V MA 02601 6/15/2020 required for every , page. Cityrrown State Zip Code Date of Inspection Inspection results.must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information cS filling out forms p a on the computer, use only the tab Christopher Maki key to move your Name of Inspector cursor-do not Cape Cod Septic Services use the return key. Company Name 350 Main Company � Company Address W Yarmouth MA 02673 Cityrrown State Zip Code 508-775-2825 SI-14423 Telephone Number,, License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3., ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 7/1/2020 ` Inspectors 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. l5insp.doc-rev.7/28/2078 ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 F, Commonwealth of Massachusetts rTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 32 BLUEBERRY HILL RD Wi D Property Address JOSEPH HAYES-524 OLD BARNSTABLE RD E FALMOUTH MA 02536 Owner Owner's Name information is required for every HYANNIS MA 02601 6/15/2020 page. City(rown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: SYSTEM IS IN WORKING CONDITION � I 2) 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): t51nsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .r7 32 BLUEBERRY HILL RD Property Address JOSEPH HAYES-524 OLD BARNSTABLE RD E FALMOUTH MA 02536 Owner Owner's Name Information is required for every HYANNIS MA 02601 6/15/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3) 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 falling to protect public health, safety or the environment. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage.Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 32 BLUEBERRY HILL RD F; Property Address JOSEPH HAYES-524 OLD BARNSTABLE RD E FALMOUTH MA 02536 Owner Owner's Name information is HYANNIS MA 02601 6/15/2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: i. 4) 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 32 BLUEBERRY HILL RD Property Address JOSEPH HAYES -524 OLD BARNSTABLE RD E FALMOUTH MA 02536 Owner Owner's Name Informarequire for is HYANNIS MA 02601 6/15/2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ to 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 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 water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA. 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 15insp.doc•rev.7/26/2018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 32 BLUEBERRY HILL RD Property Address JOSEPH HAYES-524 OLD BARNSTABLE RD E FALMOUTH MA 02536 Owner Owner's Name information is required for every HYANNIS MA 02601 6/15/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: 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,p 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)] t5lnsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form, i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v � 32 BLUEBERRY HILL RD Property Address JOSEPH HAYES-524 OLD BARNSTABLE RD E FALMOUTH MA 02536 Owner Owner's Name information Is required for every HYANNIS _MA 02601 6/15/2020 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: VACANT Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment.unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No' Water meter readings, if available(last 2 years usage (gpd)): "19- 137 GPD 18-134GPD Detail: Sump pump? ❑ Yes ® No Last date of occupancy: UNKNOWN Date r t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 32 BLUEBERRY HILL RD Property Address JOSEPH HAYES-524 OLD BARNSTABLE RD E FALMOUTH MA 02536 .Owner Owner's Name information is required for every HYANNIS MA 02601 6/15/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpa) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No f Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5lnsp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts > Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y� t.. 32 BLUEBERRY HILL RD Property Address JOSEPH HAYES-524 OLD BARNSTABLE RD E FALMOUTH MA 02536 Owner Owner's Name Information is required for every HYANNIS MA 02601 6/15/2020 page. Cityrrown State Zip Code Date of.Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): i Depth below grade: 1611 feet Material of construction: ❑cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 101+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): LINE CHECKED WITH SEWER CAMERA AND WAS FOUND TO BE CLEAN AND PROPERLY PITCHED t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 J Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 32 BLUEBERRY HILL RD Property Address JOSEPH HAYES-524 OLD BARNSTABLE RD E FALMOUTH MA 02536 Owner Owner's Name information is required for every HYANNIS MA 02601 6/15/2020 page. Cityrrown State Zip Code Date of inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 511teat 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 GALLONS Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 3" 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? ESTIMATED Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1000 GALLON TANK IN GOOD CONDITION. PVC TEES IN PLACE AND CLEAN. TANK AT NORMAL OPERATING LEVEL. COVERS 5" BELOW GRADE t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts 1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 32 BLUEBERRY HILL RD Property Address JOSEPH HAYES-524 OLD BARNSTABLE RD E FALMOUTH MA 02536 Owner Owner's Name information Is HYANNIS MA 02601 6/15/2020 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. 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 Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of-inspection) (locate on site plan): I Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: 'gallons Design Flow: gallons per day t5insp.doc rev.7/2812018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-page 11 of 18 Commonwealth of Massachusetts Tithe 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r7 32 BLUEBERRY HILL RD Property Address JOSEPH HAYES-524 OLD BARNS TABLE RD E FALMOUTH MA 02536 Owner Owner's Name Information is required for every HYANNIS MA 02601 6/15/2020 page. City/Town State Zip Code Date of inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. 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 DISTRIBUTION BOX I t5insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 32 BLUEBERRY HILL RD Property Address JOSEPH HAYES-524 OLD BARNSTABLE RD E FALMOUTH MA 02536 Owner Owner's Name Information is required for every HYANNIS MA 02601 6/15/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. 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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1-6X6 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 32 BLUEBERRY HILL RD Property Address JOSEPH HAYES-524 OLD BARNSTABLE RD E FALMOUTH MA 02536 Owner Owner's Name information is HYANNIS MA 02601 6/15/2020 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 1-6X6 PIT FOUND DRY DURING INSPECTION WITH STAIN LINE FOUND AT 2FT. 12. 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp,doo-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 4 c Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments •�7 32 BLUEBERRY HILL RD Property Address JOSEPH HAYES-524 OLD BARNSTABLE RD E FALMOUTH MA 02536 Owner Owner's Name information is S MA 02601 6/15/2020 required for every HYANNI i page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): i f t5insp.doo•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments P r 32 BLUEBERRY HILL RD `J Property Address JOSEPH HAYES-524 OLD BARNSTABLE RD E FALMOUTH MA 02536 Owner Owner's Name Information is required for every HYANNIS MA 02601 6/15/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. 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 I t5insp.doc-rev.7/2812018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts r Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 32 BLUEBERRY HILL RD Property Address JOSEPH HAYES - 524 OLD BARNSTABL"E RD E FALMOUTH MA 02536 Owner Owner's Name information is required for every HYANNIS MA 02601 6/15/2020 page. Cityfrown State Zip Code Date of Inspection. D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar j ® Shallow wells Estimated depth to high ground water: +81feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: i You must describe how you established the high ground water elevation: BOTTOM OF POOLS DRY. NO WATER 1' BELOW Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 32 BLUEBERRY HILL RD Property Address JOSEPH HAYES-524 OLD BARNSTABLE RD E FALMOUTH MA 02536 Owner Owner's Name information is required for every HYANNIS MA 02601 6/15/2020 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5lnsp.doc•rev.7/26/2018 Title 5 Ofcial Inspection Form:Subsurface Sewage Disposal System-Page 18 of le u ` CY J y ' t Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 32 Blueberry Hill Road Property Address Marianna Hegerty Owner Owner's Name information is required for every Hyannis Ma 02601 7/20/11 . page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms I on the computer, IWn use only the tab- 1. Inspector: key to move your cursor-do not Ricky L. Wright use the return Name of Inspector key. B& B Excavation, Inc. r� Company Name 14 Teaberry Lane Company Address re Sandwich MA 02563 City/Town State Zip Code 508-477-0653 S14595 Telephone Number License Number I 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: .,.Y ® Passes ❑ Conditionally Passes ❑ Falls' wm r' C) FTNeeds Further Evaluation by the Local Approving Authority NO cz, 7/20/11 Inspector's Signature Date k . 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 s ' has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. wtib a, t5ins 09/08 Title 5 Official Inspection Form:Subsurface Se ge Disposal System•Page 1 of 17 f, Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 32 Blueberry Hill Road Property Address Marianna Hegerty Owner Owner's Name information is Hyannis Ma 02601 7/20/11 required for 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: m Conditionally B) System o y Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 32 Blueberry Hill Road Property Address Marianna Hegerty Owner Owner's Name information is required for every Hyannis Ma 02601 7/20/11 page. Cityrrown 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 3 ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 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 ° 32 Blueberry Hill Road Property Address Marianna Hegerty Owner Owner's Name information is required for every Hyannis Ma 02601 7/20/11 page. Cityfrown 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 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 Q ® 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 '/2 day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 32 Blueberry Hill Road Property Address Marianna Hegerty Owner Owner's Name information is Hyannis Ma 02601 7/20/11 required for every y page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No El ® 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 11 of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CM 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 32 Blueberry Hill Road Property Address Marianna Hegerty Owner Owner's Name information is required for every Hyannis Ma 02601 7/20/11 page. Cityrrown 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? El ® 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? a= 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, v 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. ® 11 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: w. 3 � Number of bedrooms (design): Number of bedrooms (actual): •... DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): ,i t5ms•09/08', ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 4 ° W` Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments , M 32 Blueberry Hill Road Property Address Marianna Hegerty Owner Owner's Name information is required for every Hyannis Ma 02601 7/20/11 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes' E 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 ears usage d n/a 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): � y Gallons per day(gpd) Pr Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑. No , y Industrial,waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No x Water meter readings, if available: t5ins•09/08 .. - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 u Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM , 32 Blueberry Hill Road Property Address Marianna Hegerty Owner Owner's Name information is required for every Hyannis annis Ma 02601 7/20/11 page. Cityrrown 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 um in : P P 9 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•09/08 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 32 Blueberry Hill Road Property Address Marianna Hegerty Owner Owner's Name information is required for every Hyannis Ma 02601 7/20/11 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: 30 years est. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >20feet Comments (on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appeared to be in good shape no signs of leakage or blockage. Septic Tank(locate on site plan): Depth below grade: 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: Sludge depth: , ry t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form " Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 32 Blueberry Hill Road Property Address Marianna Hegerty Owner Owner's Name information is Hyannis Ma 02601 7/20/11 required for every y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 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.): Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): S „ 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts d Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 32 Blueberry Hill Road Property Address Marianna Hegerty Owner Owner's Name information is required for every Hyannis Ma 02601 7/20/11 page. Cityrrown 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -,Not for Voluntary Assessments 32 Blueberry Hill Road _ Property Address Marianna Hegerty Owner Owner's Name information is required for every Hyannis Ma 02601 7/20/11 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 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c�M 32 Blueberry Hill Road Property Address Marianna Hegerty Owner Owner's Name information is required for every Hyannis Ma 02601 7/20/11 page. Citylrown 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: ® overflow cesspool. number: 1 ❑ 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 appeared to be in good shape no sign of staining or hydraulic failure.Leaching was dry at time of inspection. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 3 in series Depth—top of liquid to inlet invert 2" 4" Depth of solids layer Depth of scum layer no scum Dimensions of cesspool 5x6 Materials of construction block Indication of groundwater inflow ❑ Yes ® No t5ins•09/08 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 32 Blueberry Hill Road Property Address Marianna Hegerty Owner Owner's Name information is required for every Hyannis Ma 02601 7/20/11 page. Cityrrown 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.): I t5ins•09/08 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 � 32 Blueberry Hill Road Property Address Marianna Hegerty Owner Owner's Name information is Hyannis Ma 02601 7/20/11 required for every page. City/Town 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 C f 3 i ; S o ° t5ins•09/08 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 32 Blueberry Hill Road Property Address Marianna Hegerty Owner Owner's Name information is required for every Hyannis Ma 02601 7/20111 page. City/Town 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: >12 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Hand augered threw dry cesspool Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 32 Blueberry Hill Road Property Address Marianna Hegerty Owner Owner's Name information is required for every Hyannis Ma 02601 7/20/11 page. Cityrrown 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 a ' t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Fee 6.d THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes RpPlicatiou for Mizpont *p-5tem Construction Permit Application for a Permit to Construct( ) Repair(J< Upgrade( ) Abandon( ) ❑.Complete System Individual Components Location Address or Lot No. 32 BLuC%e;, A'1 14ML P-"e O Owner's Name,Address,and Tel.No. 14144wKc5 MA 02foOt JA0C__. CliXJcc 3 y C{oo3�(O�O- 72(00 Assessor's Map/Parcel '�f Qbl P.O. 60'4. (oo19 aa� �, 2yfo Installer's me,Address,and Tel.No. C� )7?S-ZQ'o0 Designer's Name,Address and Tel.No. �y �AVt��J�dlt'R .�` �Vi,Oc"A_MM ��O 1�.4tN5_r wTt4&m9Wl-t Type of Building: pi v/ Dwelling No.of Bedrooms �U I'�ot Size u t'� sq. ft. Garbage Grinder ( ) Other Type of Building ">wcLLj c, No.of Persons t Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) `5�30 16--04) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of.Septic Tank y A Lei=Sc,�OL Type of S.A.S. ou&ILFWW c+`SSya©`-- >«o Description of Soil Nature of Repairs or Alterations(Answer when applicable) 9ZEDLACIL, �r16M CESSPt�,I ? 0UMF,0W Ly fT-4 SQ t4co`avE qO V'yC . Z�9*� -rC3 Dei-E-A-(A-T-je>aj of- 00JW1,XRse-Cs 'Pn--Ita. Fyf- C01411110Nr4L 1-16SS t S INSPs 010J Date last inspected:I_5 I h15�gByA tiO�—y 1 2_2)0 g Agreement: The undersigned agrees to ensure the construction and maintenance of t afo escribe on-sit dis syyste�`iYt accordance with the provisions of Title 5 of the Environ al Code d of lac t s s n tl a Certificate of Compliance has been issued by this Board of He h. Signed Z Date Application Approved by (;4 ate � G Application Disapproved by: Date for the following reasons Permit No. Ju0s, �26 Date Issued r 3a U oil 0 Fee THE COMMONWEALTH OF`MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION'- TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for Th6pont *pgtem Congtruction Permit Application for a Permit to Construct( ) Repair(✓) Upgrade;( )° Abandon( ) ❑.Complete System LJ Individual Components 32 Bt UC%epsty 1.1t« 1c.arw r c ^^ Location Address or Lot No. W-i t,N is miner's Name,Address,and Tel.No. 4 Mn. Cj2ln o( �AtJlC�c CO-P-a-,wG ((`03)(030- 22(,0 Assessor's Map/Parcel p'o" e a-& to00�9 pna_7 NIA o3214lo Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. &01u LAA.-rEL 5p MA(MSs W-f4"*LM4 Type of Building: � �, � tl4! Dwelling No.of Bedrooms sq. ft. Garbage Grinder ( ) Other Type of Building 'nwtxwM(r No.of Persons If Showers( ) Cafeteria( ) Other Fixtures �. s Design Flow(min.required) ,530 r. p p gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title t Size of.Septic Tank Fr A r V c3crboL Type of S.A.S. OU RFLOW CC:5S P00 t_ (4,x Description of Soil ^''`r Nature of Repairs or Alterations(Answer when applicable) Q-PCACC- t Q LAN GR Qv R G P,PC; f�OM C E 5 SPC)e-,a -rn OUF&FGoW W (T-W 5eKEov,,e 140 I'uC . `),jt- T-v )(.:J7E V4T-7,Dkj 0r oaAm,.CpVQG +Ptaiats. FyF COMDMONIAl two s s TS It+Spr- C-no&j . Date last inspected:-(!S 1 NSf-tC'I1G►4 ?•nra r^a N Za)OP., Agreement: The undersigned agrees to ensure the construction and maintenance oft e afo/re(described on-sit se g�eydi osal s'�' y'�stem in } accordance with the provisions of Title 5..of the Environmental Code a°nd of �o�place the ystem�in�6pertattoonsuatil a Certificate of Compliance has been issued by this Board iof Health. S��"�� �` Signed ( / r Date ( p +� Application Approved by — 1! Date / r t Application Disapproved by: r i �/ �� Date --for the-following reasons` 1•_ i .. ;._ � (/ Permit No. . d+.vU,:kj -J2 Date Issued -�3��Ur�' THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS F A o��7. Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (�) Upgraded Abandoned( )by- I )1L ,k�C`t_eW_ at 2 r,Abye 9. 1/ G+✓h,1 has been constructed in accordance with the p ovisions of Tine 5 and the for Disposal System Construction Permit No. a ctg�- a a dated Installer Designer#bedrooms !y Approved design flow A)1. %/1 gpd The issuance of this permit shall not be construed as a guarantee that the system will-function as de igned. Date � � Inspector _-No. db --- Fee too - THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE, MASSACHUSETTS Migpogal 4potem Cow6tructlon VerTYY t Permission is hereby granted to Construct ( ) Re ( ) Upgrade ( ) Abandon ( ) System located at 3 9 and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this-per 011� Date _���°wCi Approved by 1 r� Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 32 Blueberry Hill Road Property Address Janice Carrin Owner Owner's Name (j information is Centerville MA 02601 4/23/08 t required for every page. City/Town State Zip Code Daterf Ins p coon ! W D. System Information (cont.) Y 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. � 32 PA,^io A O.F a 3 CESSICOL A 'L cbvoOt g 3 OVD2F(,vW CtS$POCiC tA � L{Nle i S i3aotLsN $ gF1i_rEp �� ? "M05 7-O . 13 A2 - 2.(0' Appeag ty ' Ate " ,o4 ' � O �yo 38' I Carring T-5.doc.03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15 I Town of Barnstable Op 7HE Tp� Regulatory Services $ Sj„B Thomas F. Geiler,Director MAS& 9� �a39. Public Health .Division ArED MA'S A Thomas Mclean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-8624644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future not does this Division agree with any technical observation s and interpretations contained within this report. In addition,by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the"Disposal Work Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. � I Op THE Tp� Town of Barnstable Barnstable / \ Al-ftedCa Cslp fi ( � ,� Regulatory Services Department S, BARVs-rAULE, \ MASS. Ok i6S9. Public Health Division COA\ �m 200 Main Street Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO May 2, 2008 Janice Carring 32 Blueberry Hill Road Hyannis, MA 02601 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 32 Blueberry Hill Road, Hyannis, MA was last inspected on April 24/2008,by Brad J. White, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: Outlet line from Cesspool A to overflow needs to be replaced as it is broken and bellied. You are ordered to repair or replace the septic system within two (2) years from the date you 'receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. OF THE BOA OF HEALTH cpR , R.S., CHO Agent of the Board of Health CERTIFIED MAIL #7006 2150 0002 1041 9310 Q:\SEPTIC\Letters Septic Inspection Failures\32 Blueberry Hill Road.doc Commonwealth of Massachusetts a W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 32 Blueberry Hill Road Property Address Janice Carring Owner Owner's Name information is ��� MA 02601 4/23/08 required for every page. City/Town i State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the f computer,use 1. Inspector: only the tab key = to move your Brad J. White cursor-do not s use the return Name of Inspector 9 key. Bluewater ` Company Name 350 Main Street F Company Address .. West Yarmouth MA 02673 moon City/Town State Zip Code (508)775-2800 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 4/23/08 Inspector's Sign re 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 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. Carring T-5.doc s03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 OR Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 32 Blueberry Hill Road Property Address Janice Carring Owner Owner's Name information is required for Centerville MA 02601 4/23/08 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: B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: �--� ® Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ bm- ® broken pipe(s)are replaced ----� ® obstruction is removed Carring T-5.doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 32 Blueberry Hill Road Property Address Janice Carring Owner Owner's Name information is required for Centerville MA 02601 4/23/08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: DuM lelt 'Gultet line from Cesspool A to overflow needs to be replaced as it is broken and bellied. Otherwise system will meet pass criteria. ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: 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. 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. Carring T-5.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 32 Blueberry Hill Road Property Address Janice Carring Owner Owner's Name information is required for Centerville MA 02601 4/23108 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is.less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® 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 town 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 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. Carring T-5.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts F W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 32 Blueberry Hill Road Property Address Janice Carring Owner Owner's Name information is required for Centerville MA 02601 . 4/23/08 every page. City(rown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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- 1 0,000g pd. ❑ ® 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. Carring T-5.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 C Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 32 Blueberry Hill Road Property Address Janice Carring Owner Owner's Name information is required for Centerville MA 02601 4/23/08 every page. Cityrrown 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 ti ® ❑ 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)] Carring T-5.doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form o Not for Voluntary Assessments 32 Blueberry Hill Road Property Address Janice Carring Owner Owner's Name information is required for Centerville MA 02601 4/23/08 every page. Citylrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Unknown Number of current residents: 1 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)): 06-52gpd 07-55g pd Sump pump? ❑ Yes ® No Last date of occupancy: Current 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: Last date of occupancy/use: Date Other(describe): Carring T-5.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 32 Blueberry Hill Road Property Address Janice Carring Owner Owner's Name information is. required for Centerville MA 02601 4/23/08 every page. City/Town State Zip Code Date of Inspection D. System Information .y (cont.) General Information Pumping Records: Source of information: Both cesspools pumped on 4/28/08 by Bluewater Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1,250 gallons How was quantity pumped determined? Sight tube on truck Reason for pumping: Cesspool -required with inspection Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ® Overflow cesspool ❑ Privy ❑ o) 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): Approximate age of all components, date installed (if known) and source of information: ---lio- System was installed in approx 1964 per board of health. Were sewage odors detected when arriving at the site? ❑ Yes ® No Carring T-5.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 32 Blueberry Hill Road Property Address Janice Carring Owner Owner's Name information is required for Centerville MA 02601 4/23/08 every page. City/Town State Zip Code Date of Inspection De System Information (cont.) Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑ 40 PVC Schedule 20 PVC ® other(explain): Distance from private water supply well or suction line: N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): -P Building sewer on both cesspools are in good condition. No evidence of leakage. Septic Tank(locate on site plan): Depth below,grade: N/A 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: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Carring T-5.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 32 Blueberry Hill Road Property Address Janice Carring Owner Owner's Name information is required for Centerville MA 02601 4/23/08 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.): 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 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): Carring T-5.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 32 Blueberry Hill Road Property Address Janice Carring Owner Owner's Name information is required for Centerville MA 02601 4/23/08 every page. City(rown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) 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 Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert N/A 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 Carring T-5.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 32 Blueberry Hill Road Property Address Janice Carring Owner Owner's Name information is required for Centerville MA 02601 4/23/08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: -�- ® overflow cesspool number: 1 @ 6' x 6' ❑ 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.): Soil is dry. No signs of hydraulic failure. Vegetation is normal. Leaching pit is dry as liquid.in both cesspools has not reached outlet line to overflow. Bottom of pit is @ 8'. Augeered by hand 55" through bottom of overflow and no groundwater was encountered. Carring T-5.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 32 Blueberry Hill Road Property Address Janice Carring _ Owner Owner's Name information is required for Centerville MA 02601 4/23/08 every page. Cityrrown State Zip Code Date of Inspection De System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 2 Depth—top of liquid to inlet invert A-20" B-25" Depth of solids layer A-4 B-3 Depth of scum layer A-1/2 B-2 Dimensions of cesspool Both 6' x 6' Materials of construction Both Cynderblock Indication of groundwater inflow ❑ Yes ® No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): --'� Soil is dry for both. Neither cesspool had any indication of failure. Vegetation is normal. Both cesspools liquid level was good and not even up to outlet line to overflow cesspool. Cesspool A has 32"cover to grade. Cesspool B has 32"- 14" below grade. Both cesspools structurally sound. 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.): Carring T-5.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 32 Blueberry Hill Road Property Address Janice Carrin JOwner Owner's Name (j information is Centerville MA 02601 4/23/08 required for every page. City/'rown State Zip Code Daterf Insp coon W . D. System Information (cont.) y 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. # 32 A i. Pgi{o Aaea 3 Cass?ccL A 2 C�s�oacc.3 3 Limei 5 iecLrr u 3 BEit.e�D �ePV-xC'FA A2 - 2.(a App2ox ly ' Lasv& • 3'Q6. A Chi - Zyr 3 38% II q.T.S . Carring T-5:doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface.Sewage Disposal System Form - Not for Voluntary Assessments ^M 32 Blueberry Hill Road Property Address Janice Carring Owner Owners Name information is required for Centerville MA 02601 4/23/08 every 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: �' 12 -7 + feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within.150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers—(attach documentation) ® Accessed USGS database -explain: Well MIW-29 Zone D 4-5 Level 7.7 Adjustment 40" You must describe how you established the high ground water elevation: ---W Augeered 55"through bottom of overflow cesspool which was bone dry. Bottom of overflow cesspool @ 8'-0". No indication of groundwater @ 151". Deduct the required 40" adjustment leaves the balance at 111" The bottom of the cesspool is at 96"thus leaving us at least 15" of available room. I Carring T-5.doc+03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 r O s W z � co r o C G � � rq Cry 1 :P i � ld 0 e, � G r u�