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HomeMy WebLinkAbout0005 FIRST AVENUE (HYANNIS) - Health 5 First Avenue Hyannis A= 267 172 Commonwealth of Massachusetts Title 5 Official Inspection Form 11 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 5 First Ave ' Property Address Andrew Fox Owner Owner's Name information is H required for every y annis MA 02601 09/22/2020 page. City(rown 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 filling out forms A. Inspector Information on the computer, use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return Company Name key. 52 Rivers End Road Co � Company Address Teaticket Ma. 02536 City/Town State Zip Code 508-280-3356 S13938 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 9/23/2020 Inspector's Signature Date'` The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 ' E Commonwealth of Massachusetts �. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u— 5 First Ave Property Address Andrew Fox Owner Owner's Name information is required for every Hyannis MA 02601 09/22/2020 page. Cityrrown 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: This 4 bedroom home has an H-10 1500 gallon septic tank with a D-Box feeding 2 precast leaching pits with stone. At the time of the inspection no visible failure criteria was found. 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Ida Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ............. 5 First Ave Property Address Andrew Fox Owner Owner's Name information is required for every Hyannis MA 02601 09/22/2020 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 FIND (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 FIND (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 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts l Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 5 First Ave Property Address Andrew Fox Owner Owner's Name information is Hyannis MA 02601 09/22/2020 required for every y page. Cityrrown 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: 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 �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v— 5 First Ave Property Address Andrew Fox Owner Owner's Name information is required for every Hyannis MA 02601 09/22/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 Y2 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 CM 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 II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 5 First Ave Property Address Andrew Fox Owner Owner's Name information is required for every Hyannis MA 02601 09/22/2020 page. City/Town 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 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? ® ❑ 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. ® El approximation 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)] t5insp.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 u � 5 First Ave Property Address Andrew Fox Owner Owner's Name information is required for every Hyannis MA 02601 09/22/2020 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 plus GPD Description: Number of current residents: 0 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 Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage d town water 9 ( Y 9 (gP ))� Detail: 3f ICI - rUf- � - ItoI A-!elC If 1A5!--� Sump pump? ❑ Yes ® No Last date of occupancy: last weekend Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 5 First Ave V� Property Address Andrew Fox Owner Owner's Name information is required for every Hyannis MA 02601 09/22/2020 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(gpd) 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 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: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 5 First Ave Property Address Andrew Fox Owner Owner's Name information is required for every Hyannis MA 02601 09/22/2020 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Type o 4. T f System: . Y Y ® 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): " Depth below grade: 21 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: town water feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts ,� Title 5 Official 1 Inspection Form- _ 11 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 5 First Ave Property Address Andrew Fox Owner Owner's Name information is H required for every annis MA 02601 09/22/2020 y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 12"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) I If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: H-10 1500 gallon Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle 34" Scum thickness 5" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? sludge judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use of the home. At the time of inspection the liquid level was at working level and the tee's were in place. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 f Commonwealth of Massachusetts ,�,p Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 5 First Ave Property Address Andrew Fox Owner Owner's Name information is required for every Hyannis MA 02601 09/22/2020 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts 19 Title 5 Official Inspection Form �I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u— 5 First Ave Property Address Andrew Fox Owner Owner's Name information is required for every Hyannis MA 02601 09/22/2020 page. Citylrown 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 co attached? ❑ Yes No copy ❑ 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At the time of the inspection the liquid level was at working level and there were no visible signs of leakage or solids carryover. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments •, 5 First Ave Property Address Andrew Fox Owner Owner's Name information is required for every Hyannis MA 02601 09/22/2020 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* 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: Two ❑ 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 f Commonwealth of Massachusetts ry Title 5 Official Inspection Form I, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 First Ave V Property Address Andrew Fox Owner Owner's Name information is required for every Hyannis MA 02601 09/22/2020 page. City/Town 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.): At the time of the inspection no visible failure criteria was found. ti 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.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` c,•, !% 5 First Ave ,u— Property Address Andrew Fox Owner Owner's Name information is required for every Hyannis MA 02601 09/22/2020 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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Fo rm orm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 First Ave Property Address Andrew Fox Owner Owner's Name information is required for every Hyannis MA 02601 09/22/2020 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 J o y � M /E \ t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts I Title 5 Official Inspection Form Fig Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 5 First Ave Property Address Andrew Fox Owner Owner's Name information is required for every Hyannis MA 02601 09/22/2020 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 12 plus feet 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: I augered a hole at a lower elevation and shot it with a transit. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 t c Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u- 5 First Ave Property Address Andrew Fox Owner Owner's Name information is required for every Hyannis MA 02601 09/22/2020 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 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 r • 1, e' .1 COMMONWEALTH OF MASSACHUSETTS d Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information 1. Property Information: MAP 267— PARC 172 ��� 5 FIRST AVENUE —W. HYANNISPORT, MA 02672 C;K 6 7 Property Address ASHUR, JEFFREY Owner's Name 24 WISWALL STREET Owner's Address NEWTON MA 02645 City/Town State Zip Code r JANUARY 10, 2007 Date 2. Inspector: 1 =a F vy g JAMES D. SEARS Name of Inspector A & B CANCO E{ Company Name - 350 MAIN STREET Jf Company Address WEST YARMOUTH MA 02673 City/Town State Zip Code 508-775-2800 Telephone 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 16.340 of Title 5(310 CMR 16.000). The System: ® Passes Conditionally Passes Fails eeds Further Evaluation by the'Local Approving Authority 1 - is - o7 spector's Signature: Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 16 COMMONWEALTH OF MASSACHUSETTS d Title 5 Official Inspection Form ye v`Ob Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. Certification (cont.) 5 FIRST AVENUE Owner's Address WEST HYANNISPORT MA 02672 City/Town State Zip Code ASHUR, JEFFREY Owner's Name JAN UARY 10, 2007 Date of inspection 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: N/A ❑ 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 El 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: I Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 16 COMMONWEALTH OF MASSACHUSETTS w Title 5 Official Inspection Form d Not for Voluntary Assessments qM She" Subsurface Sewage Disposal System Form B. Certification (cont.) 5 FIRST AVENUE Owner's Address WEST HYANNISPORT MA 02672 City/Town State Zip Code ASHUR, JEFFREY Owner's Name JAN UARY 10, 2007 Date of inspection B) System Conditionally Passes (cont.): 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: 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: N/A 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 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 COMMONWEALTH OF MASSACHUSETTS a Title 5 Official Inspection Form Not for Voluntary Assessments 5 Subsurface Sewage Disposal System Form B. Certification (cont.) 5 FIRST AVENUE Owner's Address WEST HYANNISPORT MA 02672 City/Town State Zip Code ASHUR, JEFFREY Owner's Name JAN UARY 10, 2007 Date of inspection C) Further evaluation is required by the Board of Health (cont.): N/A 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. El 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 that 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 16 COMMONWEALTH OF IMASSACHUSETTS a Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) 5 FIRST AVENUE Owner's Address WEST HYANNISPORT MA 02672 City/Town State Zip Code ASHUR, JEFFREY Owner's Name JANUARY 10, 2007 Date of inspection D) System Failure Criteria Applicable to All Systems: N/A You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ® ® Liquid depth in pits is less than 6" below invert or available volume is less than '/2 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ® Any portion of the SAS, cesspool or privy is below high ground surface water elevation. N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 0 N/A An portion of a cesspool or privy is within a Zone 1 of a public well. Y P P P `N N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well. N/A 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 p pp y p q y 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.] YES No ® The system is a cesspool serving a facility with a design flow of 2000 gpd— 10,000 gpd. 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. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 COMMONWEALTH OF MASSACHUSETTS 4 Title 5 Official Inspection Form d Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) 5 FIRST AVENUE Property Address WEST HYANNISPORT MA 02672 City/Town State Zip Code ASHUR, JEFFREY Owner's Name JANUARY 10, 2007 Date of inspection E) N/A-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. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 16 COMMONWEALTH OF MASSACHUSETTS G w Title 5 Official Inspection Form o Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. Checklist 5 FIRST AVENUE Property Address WEST HYANNISPORT MA 02672 City/Town State Zip Code ASHUR, JEFFREY Owner's Name JAN UARY 10, 2007 Date of inspection Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health Were any of the system components pumped out in the previous two weeks? ® Has the system received normal flows in the previous two week period? ® Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ® Was the facility or dwelling inspected for signs of sewage back up? ® Was the site inspected for signs of break out? ® 0 Were all system components, including 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)]. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 16 COMMONWEALTH OF MASSACHUSETTS N y Title 5 Official Inspection Form d Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information 5 FIRST AVENUE Property Address WEST HYANNISPORT MA 02672 City/Town State Zip Code ASHUR, JEFFREY Owner's Name JANUARY 10, 2007 Date of inspection Residential Flow Conditions:./ Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 Number of current residents: 2 Does residence have a garbage grinder? ® Yes ® No Is laundry on a separate sewage system?[if yes separate inspection is required] ❑ Yes ® No Laundry system inspected? Yes ❑ No Seasonal use? ® 0 No Water meter readings, if available(last 2 years usage(gpd)): N/A Sump pump? ® Yes ® No Last date of occupancy: PRESENT Commercial/Industrial Flow Conditions: N/A 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): Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 16 COMMONWEALTH OF MASSACHUSETTS 4 Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 5 FIRST AVENUE Property Address WEST HYANNISPORT MA 02672 City/Town State Zip Code ASHUR, JEFFREY Owner's Name JANUARY 10, 2007 Date of inspection General Information Pumping Records: ./ Source of Information: 2005 Was system pumped as part of the inspection? ® Yes ® 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): Approximate age of all components, date installed(if known)and source of information: 1983 Were sewage odors detected when arriving at the site? ❑ Yes No Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 r COMMONWEALTH OF MASSACHUSETTS Title 5 Official Inspection Form � ° e Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 5 FIRST AVENUE Property Address WEST HYANNISPORT MA 02672 City/Town State Zip Code ASHUR, JEFFREY Owner's Name JANUARY 10, 2007 Date of inspection Building Sewer(locate on site plan): ✓ Depth below grade: 8" 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.): PVC 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: 1500-GAL PRE CAST Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle 29" Scum Thickness 1" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? ASBUILT—TAPE&SLUDGE JUDGE Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 16 COMMONWEALTH OF MASSACHUSETTS w Title 5 official Inspection Form d Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 5 FIRST AVENUE Property Address WEST HYANNISPORT MA 02672 City/Town State Zip Code ASHUR, JEFFREY Owner's Name JANUARY 10, 2007 Date of inspection Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): TANK AT WORKING LEVEL, TANK & COVERS AT 6" INLET TEE — OUTLET TEE. NO SIGN OF LEAKAGE OR OVER LOADING. Grease Trap (locate on site plan): N/A Depth below grade: feet Material of construction: concrete M 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): N/A Depth below grade: Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene other(explain) Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 16 COMMONWEALTH OF MASSACHUSETTS d Title 5 Official Inspection Form ` Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 5 FIRST AVENUE Property Address WEST HYANNISPORT MA 02672 City/Town State Zip Code ASHUR, JEFFREY Owner's Name JANUARY 10, 2007 Date of inspection Tight or Holding Tank (cont.) N/A 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 a 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 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-BOX IS 16" X 16" — 18" BELOW GRADE WITH COVER AT 6" ONE LINE IN TWO LINES OUT. BOX IS NEW 1-10-07, PERMIT #2007-010 Pump Chamber(locate on site plan): N/A Pumps in working order: El Yes No Alarms in working order: Yes ® No Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 16 COMMONWEALTH OF MASSACHUSETTS r Title 5 Official Inspection Form d Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 5 FIRST AVENUE Property Address WEST HYANNISPORT MA 02672 Cityrrown State Zip Code ASHUR, JEFFREY Owner's Name JANUARY 10, 2007 Date of inspection 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: 2 leaching chambers number: leaching galleries number: ® leaching trenches number, length: ® leaching fields number, dimensions: ® overflow cesspool number: ® innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): LEACHING IS TWO (2) 1000-GALLON PRE CAST PITS WITH 1' STONE. PITS ARE 20" BELOW GRADE, 12" WATER — STAIN LINE AT 20". NO SIGN OF OVER LOADING OR SOLID CARRY OVER. I Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 cf 16 COMMONWEALTH OF MASSACHUSETTS N Title 5 official Inspection Form a d ye y`04 Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 5 FIRST AVENUE Property Address WEST HYANNISPORT MA 02672 City/Town State Zip Code ASHUR, JEFFREY Owner's Name JANUARY 10, 2007 Date of inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): N/A 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, damp soil, condition of vegetation, etc.): Privy (locate on site plan):N/A Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 16 c COMMONWEALTH OF MASSACHUSETTS Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 5 FIRST AVENUE Property Address WEST HYANNISPORT MA 02672 City/Town State Zip Code ASHUR, JEFFREY Owner's Name JAN UARY 10, 2007 Date of inspection 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. fN`s I N f � j i v i Tide;Official insoecden Form:SuhsurSce Sewaee Disposal Svs[em Paec i i o 16 COMMONWEALTH OF MASSACHUSETTS Title 5 Official Inspection Form a Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 5 FIRST AVENUE Property Address WEST HYANNISPORT MA 02672 City/Town State Zip Code ASHUR, JEFFREY Owner's Name JANUARY 10, 2007 Date of inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to NO ground water: 12' Please indicate all methods used to determine the high ground water elevation: 0 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: TEST HOLE ON PLAN 1983 — 12' NO WATER. t. Title Official Inspection Form Subsurface Sewage Disposal System T Page 16 of 16 I' APPLICATION FOR PERCOLATION TEST AND OBSERVATION PITS ^ ti LOCATION �rl 4 r (5 f A uc r W, 11up4t. i"',/10 z. VILLAGE yu.s0ort DATE 311 q i-3 .APPLICANT Dll A'd i- XdLi� k)Q 1 o n S FEE ADDRESS ya. Me SC® a 16im, NA— TELEPHONE NO. (Non-refundable) ENGINEER �tjr+ fV( J, n C�sfi�►�vI TELEPHONE NO. DATE SCHEDULED 1�Gtart.� a� , � 3 4°3p ouM /h rofes� (Applicant' s signature) • • • • • • • o o 0 0 o o • o • o 0 o 0 o • e • • • • • o o o • o • • • • • • • • o • • • • • • • o • • • • o • • • • • • • • e • o • • • • • o • • • • • • • • • - SOIL LOG SUB-DIVISION NAME DATE ,31�5 ,72 TIME EXPANSION AREA: YES v--'NO 4 ENGINEER TOWN WATER PRIVATE WELL �.�J BOARD OF HEALTH EXCAVATOR SKETCH: (Street name,etc. ,dimensions of lot, exact location of test holes and percolation tests, locate wetlands in proximity to test holes ) NOTES: " .3. 191 _ems 0 a •G v '� v L - �- , --t q,s� v PERCOLATION RATE: /A/' TEST HOLE NO: ELEVATION: TEST HOLE NO: ELEVATION: 2 tL_ 2 i 3 3 4 4 5 .lam 5 6 6 7 8 8 9 ! V .S 9 ' 10 ,,Y��� �l� 10 i 11 ��'� 11 12 12 13 13 i 14 �' 14 15 15 16 16 ' SUITABLE FOR SUB-SURFACE SEWAGE: LEACHING FIELD/LEACHING PITS LEACHING TREN:CHES4 UNSUITABLE FOR SUB-SURFACE SEWAGE. REASONS: NOTE: ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED ON PERC TEST APPLICATION ORIGINAL: COMPLETED IN ENTIRETY BY P . E. AND RETURNED TO BOARD OF HEALTH COPY: RETAINED BY APPLICANT