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Home My WebLink About0062 HOMEPORT DRIVE - Health 62 Hoireport Drive; Hyannisr, A=268 - 128 e ° t 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 62 Homeport Drive Property Address Anna Barbara and Michael Hersey Owner Owner's Name information is Hyannis MA 02601 September 27 2012 required for every p page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not David D. Coughanowr, R.S. use the return Name of Inspector key. Eco-Tech Environmental r� Company Name 43 Triangle Circle Company Address Sandwich MA 02563 City/Town State Zip Code 508 364-0894 1328 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 M Title 5 (310 CMR 15.000). The system: W g N ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority ®1 O w- o September 27, 2012 c•+ Insp Vs Signature Date N 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. 1,0 i t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 62 Homeport Drive Property Address Anna Barbara and Michael Hersey Owner Owner's Name information is Hyannis MA 02601 September 27, 2012 required for every y P page. Citylrown 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: Inspector's Note==> The septic system described herein is deemed to pass this Real Estate Transfer Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4-5. The scope of this inspection is limited to health and environmental compliance and the septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. 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. a The septic tank is metal and over 20 years old*or the septic tank (whether meta[or not) isstructuEally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.j�System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board Q Health. - %'tea *A metal septic tank will pass inspection if it is structurally sound, not leaking aid if a Certificate, Compliance indicating that the tank is less than 20 years old-is available. ❑ Y ❑ N ❑ ND (Explain below): Ga t5ins-11/10 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 62 Homeport Drive Property Address Anna Barbara and Michael Hersey Owner Owner's Name information is Hyannis MA 02601 September 27 required for every y p , 2012 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 t , Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 62 Homeport Drive aM Property Address Anna Barbara and Michael Hersey Owner Owner's Name information is Hyannis MA 02601 September 27, 2012 required for every y p page. Cityrrown 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 62 Homeport Drive Property Address Anna Barbara and Michael Hersey Owner Owner's Name information is Hyannis MA 02601 September 27 2012 required for every -Y p page. City/Town 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. ❑ Z 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 sign ificant,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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Homeport Drive 0,. Property Address Anna Barbara and Michael Hersey Owner Owner's Name information is p required for every Y H annis MA 02601 September 27 2012 page. Citylrown 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? ® ❑ Y ( p Was the facility owner and occupants if different from owner provided with ) information on the �I n h 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): n/a Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a- no plan t5ins-11/10 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 62 Homeport Drive Property Address Anna Barbara and Michael Hersey Owner Owner's Name information is Hyannis MA 02601 September 27, 2012 required for every Y p page. Cityrrown State Zip Code Date of Inspection D. System Information Description: No design plans were found at the Board of Health or Building Department. Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 102 gpd 9 ( Y 9 (gpd)): Detail 2009, 2010 Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-11/10 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 4M 62 Homeport Drive Property Address Anna Barbara and Michael Hersey Owner Owner's Name information is Hyannis MA 02601 September 27, 2012 required for every y p page. City/Town 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 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts ti. W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 62 Homeport Drive Property Address Anna Barbara and Michael Hersey Owner Owner's Name information is Hyannis MA 02601 September 27, 2012 required for every p page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Age of all components unknown—third pit added 9110/85 (permit 85-790 at Health Dept.). Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 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.): Sewer line in basement appears in sound condition. No evidence of leakage or backup into dwelling was observed. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•11/10 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 62 Homeport Drive Property Address Anna Barbara and Michael Hersey Owner Owner's Name information is Hyannis MA 02601 September 27, 2012 required for every Y p 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 Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): 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-11/10 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 62 Homeport Drive Property Address Anna Barbara and Michael Hersey Owner Owner's Name information is Hyannis MA 02601 September 27, 2012 required for every _Y p page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M5 62 Homeport Drive Property Address Anna Barbara and Michael Hersey Owner Owner's Name information is Hyannis MA 02601 September 27 2012 required for every y p page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Homeport Drive Property Address Anna Barbara and Michael Hersey Owner Owner's Name information is H annis MA 02601 required for every Y September 27, 2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ® overflow cesspool number: 2 ❑ 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.): No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed over any component. An observation hole was dug into the stone surrounding the third component and no effluent contact staining was observed in the stone or overlying soils. No standing effluent was observed to.a depth of 2 feet below the top of the peastone layer. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 2 total - 1 primary, 2 overflow Depth—top of liquid to inlet invert 3 inches Depth of solids layer 4 inches Depth of scum layer trace Dimensions of cesspool 6 ft x 6 ft approximately Materials of construction concrete block Indication of groundwater inflow ❑ Yes ® No t5ins•11/10 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 c 62 Homep ort Drive 4'M Property Address Anna Barbara and Michael Hersey Owner Owner's Name information is Hyannis MA 02601 September 27 2012 requi-ed for every y p page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): The primary cesspool was pumped in March of this year according to owner. No adverse conditions observed. Component is constructed of concrete block. Do not drive vehicles over cesspools. 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.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth "M;assachusetts; Title 5 fficlal I s* id, Fora SVb'surface Sd. age"'D.isposa[System Form "Not'for Vol' rt ,Assessments 62',Homeport Dri've Property Address Owner Anna Barbara and Michael Hersey Owner's-Name information As required for every Hyannis MA - 02601_ 'September 21, 20.12 page. CityZrowg :State: Zip Code Date,of-lnspection D. Sysfiom; lnfO,rtnation :(;cont.)_ Ske.tch:Of Sewage,_Disposal System Provide a view of'the sewage,disposal' ,ystem, including'ties to at least two permanent referencelandma�ks or benchmarks: Locate all, ells,within 100 feet. Locate where public water supply enters,the building. Check one of the boxes below: Z hand-sketch in:the:area below 0 drawing--attached separately o , yi,.RFLo.w �SSpQar~:S. 7. z 15ins ,71/10 TiUa S Ofiidat lnspeclian Form subsurface5ewaga O.isposai system Page-15 of 17 i Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Homeport Drive Property Address Anna Barbara and Michael Hersey Owner Owner's Name information is required for every Hyannis p H is MA 02601 September 27 2012 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Previous inspection report ❑ Checked with local excavators, installers- (attach documentation) ® Accessed USGS database-explain: Barnstable GIS Department records You must describe how you established the high ground water elevation: Previous inspection report indicates high groundwater is more than 12 feet below the surface. Barnstable GIS Department records concur. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GM s 62 Homeport Drive Property Address Anna Barbara and Michael Hersey Owner Owner's Name information is Hyannis MA 02601 September 27 2012 required for every P 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 2- 6o COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAI 12 I DEPARTMENT OF ENVIRONMENTAL PR ONE WINTER STREET, BOSTON, MA 02108 617-292- 2 A ~ ADO p WILLIAM F.WELD 'tO�N 6 rDY CORE Govemor *40-a `9'9� Secretary ARGEO PAUL CELLUCCi dj you' 'tqB� -D f B.STRUHS Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F R Commissioner PART A L 5 CERTIFICATION 9 (02 f+oVV or+ %rk j4_ wrh.� '`1- Property Address: �1 Address of Owner:�c�ex-� C�1nYW Date of Inspection: I I t��`7 l (If different) Name of Inspector: ' o�caa�c�olro¢��S I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15:000) Company Name: t b C-f3 P Li S— Mailing Address: 2 C_�- 6 f,-ke:.0 Telephone Number: -7 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 sewagedisposal systems: The system:, :.. V Passes _ .Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails -� Inspector's Signature: Date: f I�� J 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: A]`SYSTEM PASSES: y I have not found any information which indicates that the system violates any of the failure criteria al defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: BI SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/23/97) page 1 of 10 DEP on the World Wide Web: http:/WWW.magnet.state.ma.us/dep CJ Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION-FORM PART A CERTIFICATION (continued) 4 _ Property Address: �� owvC—P6fL-t L. VE AotJ S�OR-T Owner: R e be-,C+ �l 1 Date of Inspection: (t— t1S-�i-j BJ 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). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed 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 HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS 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 the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS 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. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: (,p .Z 14 0 YNC PC>4"T 3b Q,k Q H y PrN M I %e b C-7 Owner: 'kcl —.R-T "1J►`)o c.'t_ Date of Inspection: L(—t%--cj-? DJ SYSTEM FAILS: You must indicate ei:!,er "Yes" or"No"as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 1S.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No _ ,�/ Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. VDischarge 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). A/ Number of times pumped_. _ v 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 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 I of a public well. 1 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: You must indicate either "Yes" or"No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: 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: 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) 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. (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: !02 °w` ef"".r+ by r tl e 2 Nf�4hn S ed Owner: R o ex`V C-oh h o I Date of Inspection: 1L- $ Check if the following have been done: You must indicate either "Yes"or"No"as to each of the following: Yeses No Pumping information was provided by the owner, occupant, or Board of Health. ' _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. 1Z _ As built plans have been obtained and-examined. Note if they are not available with N/A. V _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ 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: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)) (revised 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION. Property Address: (o?i No(mE Pc(Z l bi-kOE)H y N lu►v COR-T Owner: Co(JYVOL-L Date of Inspection: -7 FLOW CONDITIONS RESIDENTIAL: Design flow p.d./bedroom for S.A.S. Number of bedrooms:, Number of current residents: a Garbage grinder(yes or no): Laundry connected to syste (yes or no):\ Seasonal use (yes or no):-R �� J Water meter readings, if available (last two (2)year usage (gpd): 6&-4 'IS /6 . C CU. r_AA-• F] 2-1 Sump Pump(yes or no):-4L ? b c* , 7 32-� 0z CA,- , t , Last date of occupancy: Nr�111 COMMERCIAUIN DUSTRIAL: 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: System pumped as part of inspection: (yes or no)!— If yes, volume pumped: ttallons Reason for pumping: TYPE OF SYSTEM eptic tank/distribution box/soil absorption system �gle cesspool Overflow cesspool i- P 11 1 Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the.site: (yes or no) (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: C.2 141-1 wsr-E ?o R-7 IJ R\v1� ) 1 "'tc�k S o(Z 1 Owner.-ice I&--.(L-C Cc10 0 o L(�`+ 1 Date of Inspection: l t BUILDING SEWER: (Locate on site plan) Depth below grade: � Material of construction: _ t iron _40 PVC ✓other (explain)0 ra'rbvv8— Distance from pjivate water supply well or suction line Diameter q Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: 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 _Fiberglass _Polyethylene —other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 2- R-OhnIE-Pa�Z7 O V 3 t{'thN( S a)L Owner: 1�o rdE(L_ Co lJ CJ o L L y Date of Inspection: -7 TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: Material of construction: concrete `metal _Fiberglass __Polyethylene other(explain) Dimensions: Capacity: gallons Design flow: gallonstday Alarm level: Alarm in working order_Yes; _r No Date of previous pumping: _ 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) Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: A Q R-�JE ft `f A W w S P o 2 I Owner: ItQ_p BC--(2.-C C.n �-1- Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type. . leaching pits, number: leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition o vegetati , etc.) wT�C s CESSPOOLS: �- (locate on site plan) Number and configuration: , Depth-top of liquid to inlet j ert: Depth of solids layer:.ESN Depth of scum layer: 10` Dimensions of cesspool: 4 Materials of construction: Indication of groundwater: IUU� inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of;ponding, condition vegetatio , etc.) ��i t L l�;•�•i �v rti.l� iT 1 U y PRIVY:�1 (locate dh 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 04/25/97) Pago 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: (o If oh-%E t'o Z- b t20JG -to N ;S eo Owner: K06E 2-1 Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) a - � I � 0 (revised 04/25/97) Peg* 9 of 10 SUUMIJ'?FACE SEWAGE DISPOSAL SYSTEM! INSPECTION.FORFN PART C SYSTEM INFORMATION (continu6d) Property Address: " 2 Owner: o t I. Date of Inspection: 1\10 Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps I ' Check pumping records heck local excavators, installers 74use QSGS Data Describe in your own words how you established thee�High Groundwater Elevation. Must be completed) CA -- (r�gi�ad 04/SS/3'�) &�.crm 10 •)f 10 LOCATION SEWAGE PERMIT NO. y &,� A t �� f�- -9 VILLAGE 4)&-Q N& I N S T A LLER'S NAME i ADDRESS ,le-a , S NHS fe'VN e-j vs BUILDER OR... _,OWNER DATE PERMIT ISSUED C� DAT E COMPLIANCE ISSUED /� �� , �� e �., �o N o �� 1 �^ .� /f r �� :. 0 z f I �« r No.---..` ..a..7 Fps ..�.��....�... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH XV............OF...... .. ..�/$C.. c -L` ------------------------------- Applira#iun for Disposal Works Tonstrurtlun Frrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ..............• •••-- Location-Address or Lot No. ----........QC _ .... ...►j.:�eil\q --------------------•----- -•----•-�= p"i- -----•--•••• -------•------------•----------------...•.-..�--�er • Address Installer Address dType of Building Size Lot............................Sq. feet V Dwelling—No. of Bedrooms------3...............................Expansion Attic ( ) Garbage Grinder ( ) A4 Other—Type of Building ............................ No. of persons.................---.--.---. Showers ( ) — Cafeteria ( ) Q, Other fixtures ----------•---- -••------•-••-•••-•-•-••-••-••......•......-- W Design Flow........ .......................gallons per person per day. Total daily flow.....E_3_0......................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width---------------- Diameter-----.....--.... Depth................ x Disposal Trench—No.........i........... Width.... ........... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No. .... Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) `4 Percolation Test Results Performed by.......................................................................... Date........................................ 1.4 Test Pit No. 1................minutes per inch Depth of Test Pit.-----.-----..-:---_ Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ..............•-•-----------••-•--•-••.............................-•----------------••.....•-•........._...-•----.....•-------•--....-----••-•---•-••.---•- 0 Description of Soil......................................................................................................................................................................... x ---------------------- -- ----------------------•--------------------------------•----------•-------------•---------------------------------------------------------------------------------------..... ` U Nature of Repairs or Alterations—Answer when applicable--------A.00.....k-9®-0----P.iT....._TC;s.......................... - - ---------•-------------------------------------•---........---.... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iII'U 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the b healt . � Signed _ - '... - ........................ ......` I Date ApplicationApproved By..............................................=...................................................... ........................................ Date Application Disapproved for the following reasons----------------------------------------------------------------------------------------------------------------- ........... .----------------- --------------- -........................................................................................................................................... Date PermitNo......................................................... Issued_....................................................... ------ -- -.�__ _—�-'_---------------------------•---------------------------Date--- - No......................... FEs............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Alrpliration for lliipos al Works Tonstrnrtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: -• •• ��- ,A. rc�c Q: vv� .y.&..r...�y. ....................................................... Location-Address or Lot No. -•-•--•-••-•--------------- •---•------.-.-��:0_,.7--- ................................................................. Owner Address .............. ...•••••• -••...._-- . ---------------------- Installer Address Type of Building Size Lot...............:............Sq. feet DwellingNo. of Bedrooms-__. .....— ............................. Expansion Attic ( } Garbage Grinder ( ) P., Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) � Other fixtures -----------•--• ---•------••••-••••---••-•-••-••-••-...---••••••••-------•--•-•-•••-••-----••-•••••••-••••----•--••---•--••••.........•••..........-- W Design Flow........ . ....................gallons per person per day. Total daily flow------ _: ....................gallons. WSeptic Tank—Liquid'capacity.._.........gallons Length.............•.. Width................ Diameter__-_..._______ Depth................ x Disposal Trench—No..................... Width.................... Total Length.........._......... Total.leaching area....................sq. ft. Seepage Pit No..........k.......... Diameter........:_( 1.... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 0-4 Percolation Test Results Performed by.......................................................................... Date........................................ ►.a Test Pit No. I...........:....minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 •••--•••...---•••••••••••••--••----•••-•---•-•••....-------••••••-•-•-••........................••••........................................................O Description of Soil..................••_. x ------------w.............. W U Nature of Repairs or Alterations—Answer when applicable_..__. -9_9......Lo_a::v...... =i ...._..:T...�.__--•-•--•-.__-•--. Agreement: w The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate bfbCompliance has been issued by the board of h Ith. , Sined ... ... Date Application Approved By•••••-•---•----------••----•...................... Date Application Disapproved for the following reasons--------------------------------•----•-------------•----------•------------------------------------•---•---...... . ....................•--------•---------------------....------...-•----------------------........----------•----•--•--••-•••-•--•------------•-•••••----------•--•••••----------•---•••------•......•••- Date PermitNo...................................••--•----•------------ IssuedL....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ,w ntifirat a of Tontplittnrr THIS IS TO CERTIFY,�That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by-•----•--•-------------•-•--•-------.------•-----............. 5: Installer a --------------------------------•--•-----•--------------•------------------------------------ _ ,!has been i Called in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated-............................................... THE ISSUANCE OF T IS CERTIFICATE SHALL NOT BE CON RUED AS A AR TEE THAT THE SYSTEM WILL FU/CITION SATISFACTORY. DATE................. •�Q.. ----------------......................... :,.Inspector .. ..................... a THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ` ......................................OF........................ No......................... FEE........................ Permiso� reVranteg.,.Dispos al s-ernti# � a ewa e�is osal S stemto Construct r lnhiivi ��0 - CC Street as shown on the application for Disposal Works Construction Permit No...... - _ g Board of.Health ;£ DATE................................................................................ FORM 1255 A. M. SULKIN, INC., BOSTON h~