HomeMy WebLinkAbout0042 CASTLEWOOD CIRCLE - Health 42 Castlewood Circle
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COMMONWEALTH 01 MASSACHUS S
EXECUTIVE OFFICE OF ENVIR:ONME'NTAL A 1 �033
DEPARTMENT OF ENVIRONMENTA,, PROTEC
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TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUidTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION ""�� ��((
Property Address: 42 CASTLEWOOD CIRCLE HYANNIS, MA 02601 dn3 cic
Owner's Name: MR. HOTET,Z
Owner's Address: PO BOX 762 W. HVANNISPORT, MA 02672
Date of Inspection: 6/17/03
Name of Inspector: (please print) JOHN GRAC1, INC.
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O. BOX 2119 TEATICKET, MA. 02536
Telephone Number: 508-564-6813 FAX 508-564-7270
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 or 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). Tile systen-,:
X Passes
_ Conditiona11 Passes
_ Needs Furt er Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: „/17/03
The system inspector shall submi a copy of this inspection report to the Approvin-;Authority(Board of I-lealth or DEP)within
The system inspector shall submi/a
30 days of completing this inspection. If the system is a shared system or has a desibn flow of 10,000 gpd or greater,the
inspector and the system owner shall submit the report to the appropriate regional -Mce of'the DEP. The original should be
sent to the system owner and copies sent to the buyer, if applicable,and the approv;ng authority.
Notes and Comments '
SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVER`i TWO YEARS TO PROLONG THE'
SYTEM'S USEFUL LIFE.
****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.
Titles S InrnFrtinn Fnrn, rill Si,)nnn 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 42 CASTLEWOOD CIRCLE HYANNIS,MA 02601
Owner: MR. HOTETZ
Date of Inspection: 6/17/03 '
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310
CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
SYSTEM PASSED TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYTEM'S USEFUL LIFE.
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.
n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits
substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced
with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating
that the tank is less than 20 years old is available.
ND explain: n/a
n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken-or obstructed
pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of
Health):
_ broken pipe(s)are replaced
obstruction is removed
_ distribution box is leveled or replaced
ND explain: n/a
n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
_broken pipe(s)are replaced
_obstruction is removed
ND explain: n/a
Page 3 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 42 CASTLEWOOD CIRCLE HYANNIS, MA 02601
Owner: MR. HOTETZ
Date of Inspection: 6/17/03
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.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water
supply well". Method used to determine distance n/a
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and
volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy
of the analysis must be attached to this form.
3. Other:
n/a
I
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 42 CASTLEWOOD CIRCLE HYANNIS,MA 02601
Owner: MR.HOTETZ
Date of Inspection: 6/17/03
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all-inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped nLa.
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
_ X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet 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 coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be
attached to this form.]
NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in
310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
You must indicate either"yes" or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a,significant threat,or answered
"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.
A
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 42 CASTLEWOOD CIRCLE HYANNIS, MA 02601
Owner: MR. HOTETZ
Date of Inspection: 6/17/03
Check if the following have been done. You must indicate "yes" or"no" as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks?
X _ Has the system received normal flows in the previous two week period
X Have large volumes of water been introduced to the system recently or as part of this inspection ?
X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out
X _ Were all system components,excluding the SAS, located on site?
X _ Were the septic tank manholes uncovered, opened,and the interior of the tank inspected for the condition of the
baffles or tees,material of construction, dimensions,depth of liquid,depth of sludge and depth of scum?
X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance
of subsurface sewage disposal systems
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
X _ Existing information. For example,a plan at the Board of Health.
X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is
unacceptable) [310 CMR 15.302(3)(b)]
5
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 42 CASTLEWOOD CIRCLE HYANNIS, MA 02601
Owner: MR. HOTETZ
Date of Inspection: 6/17/03
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 2 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220
Number of current residents: 1
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): NO (l�
Seasonal use: (yes or no): NO
Water meter readings, if available(last 2 years usage(gpd)):� �5
Sump pump(yes or no): NO
i Last date of occupancy: n/a \�`�
J
COMMERCIAL/INDUSTRIAL o
Type of establishment: n/a 1
Design flow(based on 310 CMR 15.203): n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to the Title 5 system(yes or no): NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION
Pumping Records
Source of information: n/a
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons-- How was quantity pumped determined? n/a
Reason for pumping: n/a
TYPE OF SYSTEM
X Septic tank, distribution box, soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from
system owner) ;
_Tight tank Attach a copy of the DEP approval
Other(describe): n/a
Approximate age of all components,date installed(if known)and source of information:
NEW PIT INSTALLED IN 1992-92-430
Were sewage odors detected when arriving at the site(yes or no): NO
6
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 42 CASTLEWOOD CIRCLE HYANNIS, MA 02601
Owner: MR. HOTETZ
Date of Inspection: 6/17/03
BUILDING SEWER(locate on site plan).
Depth below grade: 18"
Materials of construction:_cast iron X40 PVC_other(explain): n/a
Distance from private water supply well or suction line: n/a
Comments(on condition of joints, venting,evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: X(locate on site plan)
Depth below grade: 12"
Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is-;e confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: 1000 GALLONSIJ
Sludge depth: I"
Distance from top of sludge to bottom of outlet tee or baffle: 33"
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 17"
How were dimensions determined: MEASURED
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.
RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.
GREASE TRAP: _(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid.levels as related
to outlet invert,evidence of leakage,etc.):
n/a
Page 8 of I 1
I .
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 42 CASTLEWOOD CIRCLE HYANNIS,MA 02601
Owner: MR. HOTETZ
Date of Inspection: 6/17/03
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches, etc.):
n/a
DISTRIBUTION BOX: X(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into
or out of box,etc.):
D-BOX IS STRUCTURALLY SOUND.
PUMP CHAMBER: -(locate on site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.):
n/a
R
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 42 CASTLEWOOD CIRCLE HYANNIS,MA 02601
Owner: MR. HOTETZ
Date of Inspection: 6/17/03
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
1000 GAL 6' X 6' leaching pits, number: 2
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a innovative/alternative system
Type/name of technology: n/a
Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
LEACH PITS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. SYSTEM SHOWS NO SIGNS
OF FAILURE. NEW PIT HAD P OF LIQUID IN IT AT TIME OF INSPECTION. STAIN LINES INDICATE PIT
HAS NEVER HAD MORE THAN P OF LIQUID IN IT.BOTTOM AT 10-OLD PIT NOT EXPOSED
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
n/a
PRIVY: (locate on.siteplan)
-Materials of construction: n/a
"Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
a
Page 10 of I I t
OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 42 CASTLEWOOD CIRCLE HYANNIS, MA 02601
Owner: MR. HOTETZ
Date of Inspection: 6/17/03
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.
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Page 11 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 42 CASTLEWOOD CIRCLE HYANNIS,MA 02601
Owner: MR. HOTETZ
Date of Inspection: 6/17/03
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 12 feet
Please indicate(check)all methods used to determine the high groundwater elevation:
NO Obtained from system design plans on record-If checked, date of design plan reviewed: n/a
NO Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators, installers-(attach documentation)
YES Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
USGS MAPS AND CHARTS- 12 FT.
tt
r TOWN OF BARNSTABLE
LOCATION �Z CA5�l2t�c�c�d. SEWAGE #
VILLAGE t1'U 1&091ti S ASSESSOR'S MAP & LOT 1 0
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY k600 G vat 1
LEACHING FACILITY: (type) (size) o%J kow USTPoo1
NO.OF BEDROOMS toK T
BUILDER OR OWNER GM t T \
PERMITDATE: *3 f�t3\$A COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the f Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) tJ� da Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by \ t�1
i
COMMONWE:1LTH OF MASSACHL�SETTS
E7�ECliTIVE OFFICE OF EN
vIRON14ENTAL AFFAIR
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STP.EET. BOSTON \L 0210c 1617J 292•550U
TRUDY CO\E
Secretary
ARGEO PAUL CELLUCC1 7 A_D B. STRL•HS
Commissioner
Governor
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
del � i a`i3 PART A
1 CERTIFICATION
1,oV. 60 ,, 11
Property Address: Name of Owner
0(,{W'06 Address of Owner:
Date of Inspection: �
Name of Inspector:(Pre a Print)
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: 47Y ��,r Fk 620 C k'i u
Mailing Address: Ana 2 :3 7?4 MKS /9 0�4-c`7
Telephone Number: Sow)G 7 /4- • �o
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true. accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
_ Conditionally Passes
_ Needs Further Evaluatio y the Local Approving Authority
_ Fails
Irupector's Signature--l- Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty (30) days of
completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and Lhe system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to'ttre
system owner and copies sent to the buyer, if applicable. and the approving authority.
NOTES AND COMMENTS
11
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revised 9/2/98 Page 1 of 11
`� Primed on Recycled Paper
I '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (contirxwed)
'roperty Address: ���1¢���ril
Jwner:
Date of Inspection:
INSPECTION SUMMARY: Check A, B, C, o/ D:
A. SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
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.
Indicate yes, no, or not determined (Y. N, or NO). Describe basis of determination in all instances. If "not determined", explain why not.
_ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
_ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
_ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if (with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
revised 9/2/98 Page 2of11
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
{ CERTIFICATION (continued)
property Address:
Owner:
Date of Inspection:
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WIT 310 CMR 15.303(1)(b)THAT THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUB C WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC H LTH AND SAFETY AND THE ENVIRONMENT:
_ The system has a septic tank and soil absorption sy tem (SAS)and the SAS is within 100 feet of a surface water supply or
tributary to a surface water supply.
_ The system has a septic tank and soil absorption ystem and the SAS is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorpti system and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and soil absorpt n system and the SAS is less then 100 feet but 50 feet or more from a
private water supply well, unless a well wat analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility nd the is
of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine d• tance (approximation not valid).
3) OTHER
J
revised 9/2 .98 Page 3of11
F
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO=M
PART A
CERTIFICATION(continued)
Property Address:
Owner:
Date of Inspection:
D. SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following:
I have determined that one or more of the following failure conditions exist as described in =10 R 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine ^-at ill be necessary to correct the failure.
Yes No
Backup of sewage into facility or system component due to an overloaded or cb SAS or cesspool.
_ Discharge or ponding of effluent to the surface of the ground or surface water d-e to an overloaded or clogged SAS or
cesspool.
_ Static liquid level in the distribution box above outlet invert due to an overl aded r clogged SAS or cesspool.
_ Liquid depth in cesspool is less than 6" below invert or available volume s less ttan 1/2 day flow.
_ Required pumping more than 4 times in the last year NOT due to clog ed or obstricted pipets).
Number of times pumped_.
_ Any portion of the Soil Absorption System, cesspool or privy is b ow the high gr3undwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surfa water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a publ' well.
_ Any portion of a cesspool or privy is within 50 feet of a pri ate water supply wet.
_ Any portion of a cesspool or privy is less-than 100 feet t greater than 50 feet`rom a private water supply well with no
acceptable water quality analysis. If the well has been nalyzed to be acceptable. attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammon' nitrogen and nitrate nitrcgen.
E. LARGE SYSTEM FAILS:
You must indicate either "Yes- or "No" to each of the following:
The following criteria apply to large systems in addition to he criteria above:
The system serves a facility with a design flow of 10.0 0 gpd or greater(Large System)and the system is a significant threat to public
health and safety and the environment because one or ore of the following conditions east:
Yes No
_ the system is within 400 feet of a surfs a drinking water supply
the system is within 200 feet of a tri tary to a surface drinking water supply
the system is located in a nitrogen ensitive area(Interim Wellhead Protection Area-IWPA) or's mapped Zone II of a public
water supply well)
The owner or operator of any such system shall Upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
revised 9/2/98 Page 4of11
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner:
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped for at least two weeks and-the system has been-receiving normal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
2 As built plans have been obtained and examined. Note if they are not available with NIA.
XThe facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
Y _ All system components, excluding the Soil Absorption System, have been located on the site.
L\ _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction, dimensions, depth of liquid,depth of sludge, depth of scum.
The.size and location of the Soil Absorption System on the site has been determined based on:
4 Existing information. For example, Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable
115.302(3)(b))
The facility owner land occupants,if different from owner) were provided with information on the properxnaintanaosof
Subsurface Disposal Systems.
revised 9/2/98 Page cof1
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
'rope"Address: 20
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design floe-9 g•p.d. bedroom.
Number of bedrooms (design):Q 3 Number of bedrooms (actual): O"Z
Total DESIGN flow 33p
Number of current residents:-0-1
Garbage grinder lyes or no::_dj
Laundry(separate system) 1 es or ol�_: If yes, separate inspection required
laundry'system inspected y or no)
Seasonal use (yes or no): If
Water meter readings. if available (last two year's usage(gpd): 1.] %FLL`ASOr,)
Sump Pump (yes or no): Iri
Last date of occupancy: AJ-I 15Sca
COMMERCIALfINDUSTRIAL:
Type of establishment:
Design flow: qpd 1 Based on 15.203)
Basis of design flow
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings,if available:
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of inform tio�
W O �CrJ2d�.
System pumped as part of inspection: (yes or no)_
If yes, volume pumped: gallons
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)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed Of known)and source of information:
Sewage odors detected when arriving at the site: (yes or no)_"v
revised 9/2/9E Page 6orll
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (contirwed)
'roperty Address: l� Swl /
Owner:
Date of Inspection:
BUILDING SEINER: b
(Locate on site plan)
Depth below grade:_
Material of construction:_cast iron_40 PVC_ other (expla.-;
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.!
SEPTIC TANK:
(locate on site pi n)
t•1
Depth below grade:
Material of construction:Alconcrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is metal, list age_ Is.age confirmed by Certificate of Compliance _ (Yes/No)
Dimensions:-
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:•aLH
Scum thickness:Otk (I
Distance from top of scum to top of outlet tee or baffle:_$_ �l
Distance from bottom of scum to bottom of outlet tee or baffle: �l�
How dimensions were determined:AA4 • k �
:omments:
(recommendation for pumping, condition of inlet and outlet tees or bAfileso depth of liquid level in relat'on to outlet invert, s`truct al integrity.
fF
avid nce of leakage etc.l l
GREASE TRAP:
(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_Fiberglass _Polyethylene—other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage,etc.)
T -
t
revised 9/2/98 Page 7of11
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (contirwed)
'roperty Address: �ti�s /
Owner:
Date of Inspection:
TIGHT OR HOLDING TANK:(Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grade:_
Material of construction: _concrete_metal_Fiberglass_Polyethylene—other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons day
Alarm present
Alarm level: Alarm in working order: Yes _ No_
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
(locate on site plan) _
1
Depth of liquid level above outlet invert: Ilk av
Comments:
ote' level and distr' utio is�` 1. den f solids carryover, evidence of lead ale into or out of box, etc.)
n it cyno
PUMP CHAMBER:AD
D
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms in working order(Yes or No)_
Comments:
(note condition of pump chamber,•condition of pumps and appurtenances, etc.)
revised 9/2/98 Page flof11
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
4operty Address:
Owner:
Date of Inspection: 3
SOIL ABSORPTIONS STEM(SAS): S
(locate on site plan, if possible: excav tion not required, location may be approximated by non-intrusive methods)
If not located, explain:
Type: �p
leaching pits, number:
leaching chambers, number:_
leaching galleries, number:_
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
( to condition of soil, signs of hydraulic failure, level of onding, damp soil, condition of vegetati n etc.)
tU
TA-qi
CESSPOOLS:
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
)epth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condtion of vegetation, etc.)
I
revised 9/2/98 Page 9of11
I
• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'roperty Address:
Jwnef: `
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
I
a
4
QrT �
4- 3q `
65' S�
revised 9/2/98 Page 10of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
/�
SYSTEM INFORMATION (continued)
roperty Address: �Z Cs-S t('(7 40:xj
Owner:
Date of Inspection:
NRCS Report named - —
Soil Type_ -- '--
Typical depth to groundwater __ _
USGS Date website visited Vl-J�
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope h O
Surface water 1->p
Check Cellar 04
Shallow wells fqhl
Estimated Depth to Groundwater LOFeet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site(Abutting property, observation hole.basement sump etc.'
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators, installers
Used USGS Data
Describe how you established the 'gh Groundwater Elevation. (Must be completed)
UISt �' �(
24
revised 9/2/98 Page II of II
TOWN OF BARNSTABLE
LOCATION ��2 SEWAGE
�t7
VILLAGE ASSESSOR'S MAP & LOT o'L?5- 7
INSTALLER'S NAME 6z PHONE NO.
SEPTIC TANK CAPACITY
i
LEACHING FACILITY:(type) i� (size) .(iCF qc- / �4
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED: �' O �✓ 2
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
Y 1