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HomeMy WebLinkAbout0745 FALMOUTH ROAD/RTE 28 - Health �F Imouth Road-(Rte 28) HraRs P r 0 Irna v IOCAT �f � SEWAGE PE �7T -NO. 9� VILLAGE 1144 m A INSTALLER'S NAME A ADDRESS ® U I L D E R OR OWNER w ken 1 DATE PERMIT ISSUED DATE COMPLIANCE ISSUED , � _ l J i N rV J Commonwealth of Massachusetts Title 5 Official Inspection Form Fr Subsurface Sewage Disposal System Form -Not for Voluntary Assessments " 746 Falmouth Road Property Address Scott Smith i 1,. Owner Owner's Nam information is required for every Hyannis MA 02601 2-12-19 J' page. City/Town State Zip Code Date of Inspection {. Inspection results must be submitted on this form. Inspection forms may not be altered In any way. Please see completeness checklist at the end of the form. Hunt l nfR Important:When A. Inspector Information filling out forms p . M'tS on the computer, use only the tab James D Sears : ;yN key to move your Name of Inspector cursor-do not c0i SEARS use the return Ca ewide Enterprises key. Company Name %�1 •F!?TIF�� 0��� 153 Commercial Street ''oi,�F'S• Ec�,��.�` —I� Company Address VQ rprntunnnttu` Mash pee !, MA 02649 City/Town 1 State Zip Code 508-477-8877 S1623 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 115.000); 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 lithe 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:, i 1. ® Passes) i 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 2-12-19 spector's Sigriature 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: Thi's 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 Y in the future�under the same or different conditions of use. i lSinsp.doc•rev.712612018 Title s otficiei nspection Form:Subsurface Sewage Disposal System-Page t of 18 III f 6 6 abed xed dH LS:ZZ 61,0Z 6 L gad i Commonwealth of Massachusetts Title 5: official Inspection Form " Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 745 Falmouthl Road Property Address Scott Smith Owner Owner's Name information is required for every Hyannis MA 02601 ' 2-12-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 3 1) System Passes: ® I have knot 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: The system is two old block c. pool's. I I 2) System Conditionally Passes: ❑ One o I 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 orexfiltration 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. i 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): t5nsp,doc-rev.7/2612018 .Title 5 Official Inspectlon Form;Subsudace Sewage Disposal System-Page 2 of 18 F 02 a5ed xed dH 99?Z 6 602 £1, gad s, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 745 Falmouth Road Property Addrass Scott Smith Owner Owner's Name information is required for every Hyannis MA 02601 2-12-19 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 pumpslalarms 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 failing 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 Of cal Inspection Form;Subsurface sewage Disposal System•Page 3 of 18 6Z 96ed xed dH 69 ZZ 6 602 E I. qad Commonwealth of Massachusetts Title 5 official Inspection Form w' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 745 Falmouth Road Property Add,,ess Scott Smith Owner Owner's Name information is required for every Hyannis MA 02601 2-12-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cunt.) ❑ 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 aseptic 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: 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.71281201a Title 5 official Inspection Form:Subanlaos Sewage Disposal System-Page 4 of 18 r ZZ a5ed xeJ dH 85ZZ 660Z E6 9aJ P Commonwealth of Massachusetts : l Title 5 Official Inspection Form A, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 745 Falmouth Road Property Address Scott Smith Owner Owner's Name information is required for every Hyannis MA 02601 2-12-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) A 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No NA ❑ ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ® Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow ❑ ® 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. 11 ® 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 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 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 Il of a public water supply well t5insp.doc-rev.V26l2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 £Z abed XeJ dH 65Z2 6 LOZ 6 1. 9aJ . r c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 745 Falmouth Road Property Address Scott Smith Owner Owner's Name information is required for every Hyannis MA 02601 2-12-19 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 CM 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 sepfi@Aw c manholes uncovered, opened, and the interior 4&dmMMk inspected for the condition of theme 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)] 15insp.doo•rev.7/26/2019 Title 5 Official Inspeclion Form:Subsurface Sewage Disposal System-Page 6 of 18 bZ a6ed xeJ dH 65Z2 6 V E 6 qaJ iI i Commonwealth of Massachusetts Title 15 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 745 Falmouth Road Property Address Scott Smith Owner Owner's Name information is Hyannis I MA 02601 2-12-19 required for every page. CitylTown i State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number)of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Description: i it _ I Numberlof current residents: Does residence have a garbage grinder? ❑ Yes ❑ . No Does residence have a water treatment unit? ❑ Yes ❑ No i If yes, discharges te: Is laundriy on a separate sewage system? (Include laundry system inspection ❑ Yes ❑_ No information in this report.) Laundry;system inspected? ❑ Yes ❑ No Seasonailuse? ❑ Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: i ' I I , i Sump pump? ❑ Yes ❑ No Last date,of occupancy: Date I I I I I I e t5insp.doc-rev.7!28r2018 f Title 5 Official Inspection Form:Subsurface sewage Disposal System-Page 7 of 18 i I 5Z abed YU dH 69:ZZ 6 XZ 6 6 qad Commonwealth �o�f�Massachusetts Commonwealth of Massachusetts 9 Title 5 Official Inspection Form till, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments U. 745 Falmouth Road Property Address Scott Smith Owner Owner's Name information is required for every Hyannis MA 02601 2-12-19 Page City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercialiindustrial Flow Conditions: Type of Establishment: Office BLDG Design flow(based on 310 CMR 15.203): 200 Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft.,etc.): 2500 SQ.FT. Grease trap present? ❑ Yes ® No Water treatment unit present? ❑ Yes ® No If yes, discharges to: Industrial waste holding tank present?. ❑ Yes ® No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No Water meter readings, if available: well Water Last date of occupancyluse: Present 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: 600 GAL. gallons How was quantity pumped determined? GAGE on Pump Truck Reason for pumping: Part of Inspection a•. t5insp.0oc•rev.7012019 Title 5 Officlal Inspection Form Subsurface Sewage Disposal system•Page s of to 9Z 95ed xPJ dH 00U 6 1,02 6 6 Qad °Feb 14 2019 13:19 HP Fax page 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 745 Falmouth Road Property Address Scott Smith Owner Owners Name information is required for every Hyannis MA 02601 2-12-19 page. City(rown State Zip Code Date of Inspection D. System Information (cont) 4. Type of System: ❑ Septic tank,distribution box, soil absorption system ® $No 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 VA 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: 1984 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 21" feet Material of construction: ❑cast iron ®40 PVC ® other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipeing is PVC and Orange Burge. t5inap.doc-rev.71261201a Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 'Feb 14 ,2019 13:35 HP Fax page 1 Commonwealth of Massachusetts Title 5 Official Inspection Form }G Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 745 Falmouth Road Property Address Scott Smith Owner Owner's Name Information is required for every Hyannis MA 02601 2-12-19 page. CifyfTown State Zip Code Date of Inspectlon D. System Information (cunt.) 6. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: a ❑ 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? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): t5insp.doc•rev.712612018 Title 5 Of Ci8l Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �� Subsurface Sewage Disposal System form Not for Voluntary Assessments 5 745 Falmouth Road u Property Address Scott Smith Owner Owner's Name information is required for every Hyannis MA 02601 2-12-19 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): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal 6ystem•Page 11 of 18 ti �Z abed xe J dH OOU 6 60Z £6 gad IE Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 745 Falmouth Road Property Address Scott Smith Owner Owner's Name information is required for every Hyannis MA 02601 2-12-19 page, City/Town State Zip Code Date of Inspection D. System Information (cunt.) 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.): i *Attach co of current pumping contract(required). Is co attached? Yes No PY P P 9 PY ❑ ❑ 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.): t5insp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 18 8Z a5ed xed dH 00U 6 602 £I, qad I Commonwealth of Massachusetts e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 0 745 Falmouth Road Property Address Scott Smith Owner Owner's Name information is required for every Hyannis MA 02601 2-12-19 page. Cityfrown 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* f 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 r number: ❑ leaching chambers number: ❑ leaching galleries number: leaching trenches number, length: ❑ leaching fields number,dimensions: ® overflow cesspool number: 1 ❑ inn ovativetalternative system k , Type/name of technology: t5insp.doc-rev.72812018 - Title 5 Official.nspection Form:Subsurface Sewage Disposal system•page 13 of 18 6Z a5ed xed dH WE 6 60Z £I• qaH Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v 745 Falmouth Road Property Address Scott Smith Owner Owner's Name information is required for every Hyannis w MA 02601 2-12-19 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) 11. Soil Absorption System (SAS)(cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc,): Leaching is a old Block Pool w/cement cover at 1%8'•8"Deep. Pool is wet on bottom. No sign of over loading or solid carry over. An A�N 12. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration 1- Depth—top of liquid to inlet invert 4r Depth of solids layer 4" Depth of scum layer Dimensions of cesspool 6'x6' Materials of construction Block Indication of groundwater inflow ❑ Yes ® No Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Main C Pool 6' Deep Block w/cover at 17".One line in w/outlet tee. Pool is old. Pool at working level. Mnsp.doc•rev.7!MG18 Title S Official Inspection Form;Subsurlace Sewage Disposal System•Page 14 018 O£ a5ed xe� dH 00:£Z 660Z 66 qaJ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 745 Falmouth Road 9P-1 Property Address Scott Smith Owner Owners Name information is required for every Hyannis MA 02601 2-12-19 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.): tsinsp.doc-rev.7/2612016 Title 5 Official Inspection Form:Subsurtace Sewage Dieposat System•Pege 15 of 18 6£ a5ed xe j dH LOU 61,N £6 gad w 1 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 745 Falmouth Road Property Address Scott Smith Owner Owner's Name information is required for every Hyannis MA 02601 2-12-19 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 to 0q 4 �r , .27 t5insp.doc•rev.7/26/2018 TIt1e 5 Official Inspec iDn Form:Subsurface sewage Disposal System-Page 16 of 18 ZE a6ed xe� dH 1,OU 6 ME E 6 qad w cam, Commonwealth of Massachusetts Title 5 Official Inspection Form r fj Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 745 Falmouth Road Property Address Scott Smith Owner Owner's Name Informrequired tion is Hyannis MA 02601 2-12-19 required for every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells N� Estimated depth torigh ground water: 14' 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: Auger T.H. 14' no G.W.. Bottom of overflow at V-8" below grade. Bottom of overflow at 4'-4"above T.H. Depth, Before filing this Inspection Report, please see Report Completeness Checklist on next page. Wnsp.doc•rev.7126R018 Title 5official Inspection Form;Subsurface Sewage Disposal System•Page 17 of 18 ££ a5ed xe� dH XU 6 X2 6 6 9aJ Commonwealth of Massachusetts IF Title 5 Official Inspection Form t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 745 Falmouth Road Property Address Scott Smith Owner Owner's Name information is required for every Hyannis _ MA 02601 2.12.19 page. City/Town 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 6: 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 �aoz iz cjvsjel 0 w, t5insp.doc-rev,7121312D15 Title 5 Official;rts eclion Form Subsurface Sewage O i P a9 sposal System•page 78 of 1B b£ abed xeJ dH 1,OU 61.02 £l• qad ,4 \ COMMONWEALTH OF MASSACHUSETTS 2 !s q-'� EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OEr 7 F MENTAL PROT,E.CTION JAB ?�l�s� . . LOT TOW, ABLE �Lr HEALTH DEPT. I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ACE SEWAGE DISPOSAL SYSTEM FORM PART A '7 q�� CERTIFICATION -,Property Address: S Owner's Na e• Owner's Address: Date of Inspection: Z^ t: M Name of Inspector• le s Ae Company Name: ep Mailing Address: 11) Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes 1 Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails j ff Inspector's Signature:'' Date: k.0 i 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 isent to the system owner and copies sent to the buyer, if applicable,and the approving authority. } j Notes and Comments j ****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. j Title 5 Inspection Form 6/15/2000 page 1 1 i Page 2 of 11 i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: , Owner: Date of Inspection: kn 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: 1^ t^© T— eC 0 2t�`n t (N- oILL System Conditionally Passes: or more system components as described in the"Conditional Pass"section need to be replaced repaired.Th stem,upon completion of the replacement or repair,as approved by the Board of Heal ,will pass. Answer yes,no or not termined(Y,N,ND)in the for the following statements. If". t determined"please explain. The septic tank is metal over 20 years old* or the septic tank(wh er metal or not)is structurally unsound,exhibits substantial infiltr 'on or exfiltration or tank failure is i inent. System will pass inspection if the existing tank is replaced with a compl ' septic tank as approved b e Board of Health. *A metal septic tank will pass inspection i it is structurally s.oun of leaking and if a Certificate of Compliance indicating that the tank is less than 20 years o is available. ND explain: Observation of sewage backup or break o or hi tatic water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled o even distr: tion box. System will pass inspection if(with- approval of Board of Health): bro n pipe(s)are replaced struction is removed distribution box is leveled or replaced ND explain: The system re tred pumping more than 4 times a year due to broken or obstructed p' (s).The system will pass inspection if th approval of the Board of Health): broken pipe(s)are replaced obstruction is removed N explain: 2 raga��t t t ~ OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTTIFICATION(continued) Property Address: vc! 1 Owner: Date of Inspection: 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 fail'n to protect public health,safety or the environment. 1. Syste will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) at the system i of functioning in a manner which will protect public health,safety and the envir ment: _ Cesspool rivy is within 50 feet of a surface water _ Cesspool or vy is within 50 feet of a bordering vegeta'te�d wetland or a salt marsh 2. System will fail unless the Boar f Health(and Public Water Suppl' ,if any)determines that the system is functioning in a manner that otects the public health,safet and environment: _ The system has a septic tank and soil sorption system(SA and the SAS is within 100 feet of a surface water supply or tributary to a surface ater supply. — The system has aseptic tank and SAS and the AS is ithin a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the S within 50 feet of a private water supply well. _ The system has a septic tank and SAS and t SAS is les han 100 feet but 50 feet or more from a private water supply well".Method used to de rmine distance "This system passes if the well water ana sis,performed at a DEP rtified laboratory, for coliform bacteria and volatile organic compounds. dicates that the well is free m pollution from that facility and the presence of ammonia nitrogen and itrate nitrogen is equal to or less t 5 ppm,provided that no other failure criteria are triggered.A copy f the analysis must be attached to this rm. 3. Other: 3 Page 4 of 11 •s OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: 61 Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No 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 JStatic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than'/,day flow 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 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.] (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. Large Systems: To be c ered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,0 gpd• You must indicate eit es"or"no"to each of the following- (The following criteria app large systems in addition to the criteria above) yes no the system is within 400 feet of a s ce drinking water supply _ the system is within 200 feet of a tributary to a ace g water supply _ the system is located in a nitrogen sensitive are terim head Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any qu . n in Section E the system is considered a sign t threat,or answered "yes"in Section D above the 1 system has failed.The owner or operator of any large system sidered a significant threat under ion E or failed under Section D shall upgrade the system in accordance wi 0 CMR 15.304.The syst wner should contact the appropriate regional office of the Department. 4 Page 5ofII .f OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 11 _ tl Owner: Date of Inspection: Check if the following Have been done.You must indicate`yes"or"no"as to each of the following: Yes No 1-oS Pumping information was provided by the owner,occupant,or Board of Health i _ g�D 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? _ k Q 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 breakout _ 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? 495 _ 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: i Yes no j Existing information.For example,a plan at the Board of Health. NES_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance fs unacceptable)[310 CMR115.302(3)(b)J e • r i i 5 Page 6ofII OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: a Owner: GY'AA Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CI 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no):1".© Is laundry on a separate sewage system(yes or no):3Z[if yes separate inspection required] Laundry system inspected(yes or no):11,0 Seasonal use:(yes or no):NLb Water meter readings, if available(last 2 years usage(gpd)): 1J t A Sump pump(yes or no):INO Last date of occupancy:4Laint COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): and Basis of design flow(seats/persons/sgft,etc.): 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/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval _Other(describe): a Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no):J20 6 Page 7ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: � Date of Inspection: BUILDING SEWER(locate on site plan) is r/ • ' - Depth below grade: 1 ` Materials of construction: cast iron .J 40 PVC_other(explain): Distance from private water supply well or suction line: }t��N n Comments( n conditi n of joints,venting,evidence of leakage,etc.)• ano 0 ��(� S \-AV\S y � use SEPTIC TANK: J (locate on site plan) ('of\ e�� t� C2SS Oct Depth below grade:�y — ' Material of construction: concrete_metal fiberglass_polyethylene oc -s —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or rio):_(attach a copy of certificate) yr Dimensions: -- _ Sludge depth: L4 Distance from top of sludge to bottom of outlet tee or baffle: y Scum thickness: Y\ r)r Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or a1fle: How were dimensions determined: P rDb<.d. Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,a idence of leakage,etc 'i--r-Ay -GREASE TRAP:_(locate on site plan) Depth be ade: Material of cons ion:_concrete_metal_fiberglass_polyethylene o (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or Distance from bottom of scum to bottom utlet tee or Date of last pumping: '. Comments(on pumping rec endations,inlet and outlet tee or baffle c lion,structural integrity, liquid levels as related to outlet rove vidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: GHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth w grade: Material o nstruction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: allons Design Flow: N, allons/day Alarm present(yes or no): Alarm level: Alarm m wo ing order(yes or no): , Date of last pumping: Comments(condition of alarm and float sw hes,etc.): DISTRIBUTION BOX: (if present must be op ed)(loc on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distributio to outlets equal,any evi ce of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: ( cate on site plan) Pumps in working orde yes or no): Alarms in working o er(yes or no): Comments(note dition of pump chamber,condition of pumps and appurtenances,etc.): 8 ° Page 9 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: V\ . Owner. Date of Inspection: 1.6 � 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 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.): ) nc CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: 2 Depth—top of liquid to inlet invert: Depth of solids layer: '-i Depth of scum layer: Y1 Yl 2 Dimensions of cesspool: c6 0 S Materials of construction: S Indication of groundwater inflow(yes or no): Comments(note co dition of soil, igns of hydraulic failure,level of ponding,condition of vegetation,etc.): U VY: (locate on site plan) Materials of cons n: Dimensions: Depth of solids: Comments(note condition of soil,signs of by �cfailure, e g,condition of vegetation,etc.): 9 Page 10 of I 1 ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:-)(os `tmo � 'Owner: Date of Inspection:) O ! -I f3 L-A 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. \3Ac1- A L g 661 LAJUIV 10 c Page 11 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: �MnAiN n r\ Owner: Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: r �1 X) — 2�d 2U r1 e p C' �J CJ 1 You must describe how you established t high round ter elevation- .r l h r` e 11