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HomeMy WebLinkAbout0030 FISHER ROAD - Health 30 Fisher Rd 310-287 Hyannis ° C Commonwealth of Massachusetts 310-c2e'7 v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments rri 30 Fisher Road Property Address W Robert&Carol Harlow Owner Owner's Name Q? information is a required for every Hyannis Ma 02601 9-9-16 page. City/Town State Zip Code Date of Inspection tt} 14� LJ 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. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Matthew Gilfoy use the return Name of Inspector key. B&B Excavation „b Company Name 374 Route 130 AIX Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S113640 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 9-9-16 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 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 �v Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 30 Fisher Road Property Address Robert&Carol Harlow Owner Owner's Name information is required for every Hyannis Ma 02601 9-9-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System was in working order at time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 30 Fisher Road Property Address Robert& Carol Harlow Owner Owner's Name information is required for every Hyannis Ma 02601 9-9-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form oI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Fisher Road Property Address Robert&Carol Harlow Owner Owner's Name information is required for every Hyannis Ma 02601 9-9-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for 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. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17; Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 30 Fisher Road Property Address Robert&Carol Harlow Owner Owner's Name information is y required for every Hyannis Ma 02601 9-9-16 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private•water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large.Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 30 Fisher Road Property Address Robert& Carol Harlow Owner Owner's Name information is required for every Hyannis Ma 02601 9-9-16 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (Actual) _3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 30 Fisher Road Property Address Robert& Carol Harlow Owner Owner's Name information is y required for every Hyannis Ma 02601 9-9-16 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No 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 See below 9 ( Y 9 (gP ))� Detail: 2014-69GPD (25,432gallons) 2015- 55GPD (20,196gallons) Sump pump? ❑ Yes ® No Last date of occupancy: 5 months agoDate Commercial/Industrial Flow Conditions: Type of Establishment: NA 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: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 Fisher Road Property Address Robert&Carol Harlow Owner Owner's Name information is required for every Hyannis Ma 02601 9-9-16 page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner- last pumped 2009 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) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 30 Fisher Road Property Address Robert& Carol Harlow Owner Owner's Name information is required for every Hyannis Ma 02601 9-9-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1-18-1997 per permit Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 18" feet Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10' from town water feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 101, 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: 1500gallons Sludge depth: 8" — t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 Fisher Road Property Address Robert& Carol Harlow Owner Owner's Name information is required for every Hyannis Ma 02601 9-9-16 _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 24 Scum thickness 5 Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was in working order at time of inspection with liquid level equal to outlet invert. Tank is in need of pumping at this time and should be pumped every two years for maintenance. Grease Trap (locate on site plan): Depth below grade: NA 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 30 Fisher Road Property Address Robert& Carol Harlow Owner Owner's Name information is required for every Hyannis Ma 02601 9-9-16 _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Fisher Road Property Address Robert& Carol Harlow Owner Owner's Name information is required for every �H annis Ma 02601 9-9-16 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 11 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 was in working order at time of inspection with no signs of back up. 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.): NA * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM 30 Fisher Road Property Address Robert& Carol Harlow Owner Owner's Name information is required for every Hyannis Ma 02601 9-9-16 page. CityFrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: — ® leaching trenches number, length: 4 infiltrators 11'x25'x2' ❑ 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 was in working order at time of inspection. Infiltrators were dry when inspected with to sign of high staining. Cesspools,(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 30 Fisher Road Property Address Robert& Carol Harlow Owner Owner's Name information is required for every �H annis Ma 02601 9-9-16 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 Fisher Road M Property Address Robert& Carol Harlow Owner Owner's Name information is required for every Hyannis Ma 02601 9-9-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately REAR OF GARAGE 1 1-1`1'6" A2- 12'6" 132 17'6"y A3-,i 83-2 1' t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 c Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 Fisher Road Property Address Robert&Carol Harlow Owner Owner's Name information is y required for every Hyannis Ma 02601 9-9-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 22 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: From previous inspection report were town maps and charts were used ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: See above Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 f Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 Fisher Road M SV 9 e Property Address Robert& Carol Harlow Owner Owner's Name information is required for every Hyannis Ma 02601 9-9-16 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE �, LOCATION 3b ��'`ems , SEWAGE # q-7. a g VILLAGE HyA AIS ASSESSOR'S MAP& LOT31 a& INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY �S(Ty IL LEACHING FACILITY: (type) (size) I NO.OF BEDROOMS 3 BUILDER OR OWNER Qd �41/W)AU Sk PERMITDATE: COMPLIANCE DATE: �� 30 R7 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by I _- r� ... r ,� � a :� . 0� T l,, A . � W � � � � l � � � � - c s; �, �'� ;. . .. :�, ;�. �. � �, lr ��� TOWN OF BARNSTABLE LOCATION SEWAGE# Z : a VILLAGE— ASSESSOR'S MAP& LOT 31b 8 7 INSTALLER'S NAME&PHONE NO ��c.�— •GJ `S SEPTIC TANK CAPACITY 00 LEACHING FACILnY: (type) Y ` ,12e-i y T1'6G (size) NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: �' �-l —�i 7 COMPLIANCE DATE: � `� Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist . within 300 feet of leaching facility) Feet Furnished by �� ,.. . �' rr � -O � � � � � 1� �\ i ti ,. � � 2)/ 0 No. :�wFee v THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Application for �Bizwal *rwm Construction Vetmtt Application for a Permit to Construct( )Repair(�/)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 3 e✓ A-10 Owner's Name,Address and Tel.No. �s �7�C Assessor's Map/Parcel W e-l/ cel e-7 I y' — �� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. ao 9&2erc - /& // Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow __3:30 gallons per day. Calculated daily flow a gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank / S00 Type of S.A.S. Description of Soil A-0 Nature of Repairs or Alterations(Answer when applicable) —i�57"7a�/ SOD G G- Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 f the Environmenta a and not to place the system in operation until a Certifi- cate of Compliance has been issued b th' o Sign d Date Application Approved by Date Application Disapproved for the following reasons Permit No. "' Date Issued All rv/ No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION- TOWN OF BARNSTABLE., MASSACHUSETTS Zippfication for �Ngpogar *pgtem Construction Permit Application for a Permit to Construct( )Repair(,/)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 30 (4 F-o Owner's Name,Address/and Tel.No. 1-4—/+4r� s�t� In r,s Assessor's Map/Pazcel 3 10 - Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. as Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 30 gallons per day. Calculated daily flow 3 gallons. Plan Date Number of sheets Revision Date Title ;' ' f Size of Septic Tank / <;"100 Type of;S:A.S:; :A Description of Soil Nature of Repairs or Alterations(Answer when applicable) _r!, r ST-oad C-1 e 1 i C_­v 4��h Date last inspected: Agreement: . The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 f the Environmenta ode and not to.place`the system in operation until a Certifi- cate.of Compliance has been issued b thison-ef-Wa { Sign d Date _ Applicatiori;Approved by Date F .Application Disapproved for the followT* g reasons j 1 Permit No. Date Issued —————————--——————— —————— —--- ---- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS { Certificate of Compliance THIS IS TO CERTIFY,that the On-si ewage Disposal System Constructed( )Repaired (✓ ) Upgraded( ) Abandoned( )by at j &,-Pj has-been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 7 9 dated Installer Designer The issuance of this permit shall not be cons ed as a guarantee that the system will fun ion ads-designed. Date ^- f Inspector Jv ------—------------------------ ——— No. "'. Fee t THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLEs MASSACHUSETTS Mi.5pont *p5tem ongtruction Permit Permission is hereby granted to Construct( )Repair( Upgrade( )Abandon( ) System located at C'1.CA and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following localprovisions p y g oca or special conditions. Provided:Cons tion dust be completed within three years of the date of th s e D 4M.,,Jo 0 Date: Approved by II/ f NOTICE: This Form is to be used for the Repair of Failed Septic Systems Only CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I, 20�� ICEd` , hereby certify that the application for disposal works construction permit signed by me dated /_ / 5 7 , concerning the property located at 30 meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. SIGNED : I DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. j xert ��,. �. ,�-.��� ---�- Q ® �^ F t r COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL P�WMCOVED APR 12 2001 TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 30.Fisher Road Hyannis, MA Owner's Name: Robert Kavanaugh Owner's Address: Same Date of Inspection: April 10, 2001 Map: 310 Parcel. 287 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O. Box 49 Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant-to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority i Inspector's Signature: Date: April 10, 2001 The system inspector shall subm 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. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM —.� r__._.,._.... .... PART A CERTIFICATION (continued) Property Address: 30 Fisher Road Hyannis, MA j Owner: Robert Kavanaugh Date of Inspection: April 10, 2001 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is.replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): 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: 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 30 Fisher Road Hyannis, MA Owner: Robert Kavanaugh Date of Inspection: April 10, 2001 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 30 Fisher Road Hyannis, MA Owner: Robert Kavanaugh Date of Inspection: April 10, 2001 D. System Failure Criteria applicable to all systems: You must indicate either"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 cesspool is less than 6"below invert or available volume is less than '/Z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public 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.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 30 Fisher Road Hyannis, MA Owner: Robert Kavanaugh Date of Inspection: April 10, 2001 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? ✓ 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: Yes No _ 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(3)(b)]. 5 Page 6 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 30 Fisher Road Hyannis, MA Owner: Robert Kavanaugh Date of Inspection: April 10, 2001 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 3 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): 2000-24,750 gals.; 1999-23,250 gals. Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd 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: None on file(new system) -per treatment plant Was system pumped as part of the inspection(yes or no): 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: Jan. 30 1997- per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 30 Fisher Road Hyannis, AM Owner: Robert Kavanaugh Date of Inspection: April 10, 2001 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: S" Material of construction: ✓ concrete _metal _fiberglass polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1500 gal. Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 31" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 10" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How were dimensions determined: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): The tees were present. The liquid level was even with the outlet invert. There were no signs of leakage. I GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence 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: 30 Fisher Road Hyannis, MA Owner: Robert Kavanaugh Date of Inspection: April 10, 2001 TIGHT or HOLDING TANK: None (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even 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.): The D-box wa.F level There were no signs of leakage or solids. There were no signs of back-up from the leach field. The outlet invert to grade was approximately 30" PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 30 Fisher Road Hyannis, MA Owner: Robert Kavanaugh Date of Inspection: 4pril 10, 2001 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: 4-Hi cap. infiltrators(11'x 25'x 29-per as built card 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.): The infiltrators were located, but not dug up. There were no signs of failure in the D-box. The bottom to grade was approximately 46". CESSPOOLS: None (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 or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 30 Fisher Road Hyannis, MA Owner: Robert Kavanauzh Date of Inspection: April 10, 2001 Map: 310 Parcel. 287 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. aA�k GA(A GC A O 1 a Al- 3ib- Aa- �a Qa- ,�•c� A3 - �y i33- al 10 I Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 30 Fisher Road Hyannis,MA Owner: Robert Kavanaugh Date of Inspection: April 10, 2001 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: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high groundwater elevation: The bottom of the infiltrators to grade was approximately 46". Using the Barnstable topographic map and the Cape Cod Commission water contours map the maps were showing approximately 22'+1-to groundwater at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,written or implied,relating to the system, the inspection and/or this report. 11 TOWN OF BARNSTABLE LOCATION —3G '%�,"-- L W Q SEWAGE # Zzle VILLAGE----AJ4 vy—AA S ASSESSOR'S MAP & LOT 3.1b a S 7 INSTALLER'S NAME&PHONE NO: •9c.,r SEPTIC TANK CAPACITY r—r � LEACHING FACIL]TY: (type) 1_ S��C-12e-1-1 (size) NO.OF BEDROOMS / J BUILDER OR OWNER /fyl d PERMITDATE: ) / 'T 7 COMPLIANCE DATE: b =��_ Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by C1 v COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AIRS B O DEPARTMENT OF ENVIRONMENTAL PRO ON%oF , 199? ONE WINTER STREET,BOSTON MA 02108 (617) 292-550 y�<TTge�E WUJJ"F.WELD Y COXE Governor Secretary ARGEO PAUL CELLUCCI V��'Imo. mod. �M A•►� (2��v�� �v:, DAVID B. STRUHS Lt. Governor Commissioner ,1 WAA SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 30�i� ZA3 �}�ip�t.��8 11u1 rr4. Address of Owner: Date of Inspection: i t k`on dZ)l4=j\ (If different) Name of Inspector: Company Name, Address and Telephone Number: /ac�a���G�tiL'�w^t��v�:+.itaS �1.0`�ox'��4t'►yt'��(3Z�.)�A. �Zi�y� Shy-1> ~li{ZC CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _ Passes Conditionally Passes — Tc� `maaz *,e, �► kh �"+'�`'�— � o� Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: �Isl, Date:4 V \q� The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: y 01 3 g A] SYSTEM PASSES: N I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11/03/95) A - _.-!!_Printed-nn Rnrvrled Paror pry " SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ( ' PART A i CERTIFICATION (continued) r1 �- a�.C� 1• 'I Property Owner: ' Date of-Inspection: B] SYSTEM-CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box..-The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced -' obstruction is removed — distribution box is levelled or r placed' t"c"'""_" rtvz N-uN'ea °�'A % The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTWAND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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. 3) OTHER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be cont the failure. acted to determine what will be necessary to correct ' Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground r surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet/invrt due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert ailable volume is less than 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 10.Zfeet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: a The system serves a facility with a design flow of 10,000 gpd or greater (Large,System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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). y The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00;'and 6.00. Please consult the local regional office of the Department for further information. l (revised 11/03/95) // 3 f/ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 2© ZiN, Owner: a� t Date of Inspection: Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. N-JIA, As built plans have been obtained and examined. Note if they are not available with N/A. Y The facility or dwelling was inspected for signs of sewage back-up. i The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout.-- 'b6,vmL All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: F4+c��a_ Owner: kA \\ Date of Inspection: 4\e A"t t 'FLOW CONDITIONS RESIDENTIAL: Design flow: Jl> gallons Number of bedrooms: o`er Number of current residents:02, Garbage grinder(yes or no): 00 Laundry connected to system (yes or no): ram• -s Seasonal use (yes or no):v-)O . I a .if♦ Water meter readings, if available: 75 '`b 1%O 5 b f-11 1.ZS'Q lam:¢ d15 — Q Last date of occupancy: .t�d— COMMERCIAUINDUSTRIAL: Type of establishment: Design flow: gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: zwvvri Ge c) ��N\,L 4.0, System pumped as part of inspection (yes or no) 1,10 If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) , Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: Q�PR Sewage odors detected when arriving at the site: (yes or no) (revised 11/03/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SEPTIC TANK:_ (locate on site plan) Depth below grade: Material of construction: _concrete_metal _FRP other(explain) 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 o baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) GREASE TRAP:_ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP _other(explain) Dimensions: Scum thickness: Distance from top of scum1,to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: TIGHT OR HOLDING TANK:_ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP—other(explain) / Dimensions: Capacity: galldns Design flow: Qallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER:_ (locate on site plan) Pumps in working order.(yes or no) Comments: (note condition of pump c a Z, condition of pumps and appurtenances, etc.) (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excav tion not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: a Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: i G Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,ettc,.) r wwa�c�sGwv �'aIJ" �',o�ta 5�•� s��z'�vf, ,a 4.;c�.: �v�\;'� S tA'��2c`, , " 1Q�v�,� off- Qc.�d,rv�. ESSPUULFS XAJue fZs�2 \cam. NQ'tvr�.X. t wt�Gw-S 1,-Cz� C>- CM.»Sk.<w (locate on site an) ` Number and configuration: i \Q-""A. Depth-top of liquid to inlet invert: AYr�,:2 k 1s N Depth of solids layer: Depth of scum layer: t `� Dimensions of cesspool: tx:x� Materials of construction: Csrs r Indication of groundwater: tJt� inflow (cesspool must be pumped as part of inspection) "�`� vv\ v�M��: :,vv,,�3 c . Vm— �omments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) C.gN'CL'3j'- "' CO\ C-,\ - Nc' ' 1wnC, -va'-)OLAJ m� tiiv�4v.►+-�� v` V", c. 5— .` Tc�w.�� a—A i PRIVY:_pD c;� t��• '`�S"' � 4� 7!xol ,- (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.) (revised 11/03/95) 8'• f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 30�,sh�� Owner: `` Date of Inspection: I,, �Go SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' DEPTH TO GROUNDWATER Depth to groundwater: -'—' M feet method of determination or approximation: L.S, CrL (revised 11/03/95) 9