HomeMy WebLinkAbout0072 ISALENE STREET - Health 72 IsaleneStreet T
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFF IR
DEPARTMENT OF ENVIRONMENTAL PROTEC
'TY64
a ' d REC
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NOV 2 0 2003
TOWN OF BARNSTABLE
TITLE 5 HEALTH DEPT.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
ST • CERTIFICATION MAP
Property Address: 72 ISALENJ WEST HYANNISPORT,MA 02672 ����� PARCEL ,, C)4
Owner's Name: MR.GASBARRO
Owner's Address: PO BOX 144 WEST HYANNISPORT,MA 02672 LOT -
Date of Inspection: 10/17/03
Name of Inspector: (please print) JOHN GRACI,INC.
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536
Telephone Number: 508-564-6813 FAX 508-564-7270
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is
true,accurate and complete as of the time of the inspection. The inspection was performed based 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:
X Passes
_ Conditionally sses
_ Needs Further; aluation by the Local Approving Authority
_ Fails
t,
Inspector's Signature: ( Date: 10/17/03
i
The system inspector shall submit a cop of this inspection report to the Approving Authority(Board of Health or DEP)within
30 days of completing this inspection. he system is a shared system or has a design flow of 10,000 gpd or greater,the
inspector and the system owner shall su mit 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
SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY ONE TO TWO YEARS TO PROLONG
THE SYSTEM'S USEFUL LIFE.
****This report only describes conditions at the time of inspection and under the conditions of use at that time. This
"inspection does not address how the system will perform in the future under the same or different conditions of use.
Title S Imnectinn Fnrm rills moo 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 72 ISALENE WEST HYANNISPORT,MA 02672
Owner: MR.GASBARRO
Date of Inspection: 10/17/03
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310
CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
SYSTEM PASSED TITLE V INSPECTION.RECOMMEND PUMPING EVERY ONE TO TWO YEARS TO
PROLONG THE SYSTEM'S USEFUL LIFE.
B. System Conditionally Passes:
_ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,
upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain.
n/a The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits
substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced
with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating
that the tank is less than 20 years old is available.
ND explain: n/a
n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed
pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of
Health):
_ broken pipe(s)are replaced
_ obstruction is removed
_ distribution box is leveled or replaced
ND explain: n/a
n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
_broken pipe(s)are replaced
_obstruction is removed
ND explain: n/a
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 72 ISALENE WEST HYANNISPORT,MA 02672
Owner: MR. GASBARRO
Date of Inspection: 10/17/03
C. Further Evaluation is Required by the Board of Health:
_ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to
protect public health,safety or the environment.
I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is
not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water
supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water
supply well".Method used to determine distance n/a
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and
volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy
of the analysis must be attached to this form.
3. Other:
n/a
Page 4 Qf I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 72 ISALENE WEST HYANNISPORT,MA 02672
Owner: MR. GASBARRO
Date of Inspection: 10/17/03
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all-inspections:
Yes No
_ X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
_ X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped 1 MONTH AGO BY OWNER.
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
_ X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone I of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with
no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP
certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.]
NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in
310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered
"yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat
under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
a
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 72 ISALENE WEST HYANNISPORT,MA 02672
Owner: MR. GASBARRO
Date of Inspection: 10/17/03
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks?
X _ Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection?
X Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out`?
X _ Were all system components, excluding the SAS, located on site?
X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the
baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance
of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
X _ Existing information. For example, a plan at the Board of Health.
X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is
unacceptable) [310 CMR 15.302(3)(b)]
5
Page 6 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 72 ISALENE WEST HYANNISPORT,MA 02672
Owner: MR.GASBARRO
Date of Inspection: 10/17/03
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: 2
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)): j�
Sump pump(yes or no): NO V C�oo
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL 1_-
Type of establishment: n/a
Design flow(based on 310 CMR 15.203): n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to the Title 5 system(yes or no): NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION
Pumping Records
Source of information: 1 MONTH AGO BY OWNER
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a
Reason for pumping: n/a
TYPE OF SYSTEM
Septic tank, distribution box, soil absorption system
X Single cesspool
X Overflow cesspool
_Privy
_Shared system(yes or no)(if yes, attach previous inspection records, if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from
system owner)
_Tight tank Attach a copy of the DEP approval
Other(describe): n/a
Approximate age of all components,date installed(if known)and source of information:
1962 PER OWNER
Were sewage odors detected when arriving at the site(yes or no): NO
F
Page,7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 72 ISALENE WEST HYANNISPORT,MA 02672
Owner: MR. GASBARRO
Date of Inspection: 10/17/03
BUILDING SEWER(locate on site plan)
Depth below grade: 12"
Materials of construction:_cast iron _40 PVC Xother(explain): ORANGEBURG
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: (locate on site plan)
Depth below grade: 0"
Material of construction: Xconcrete_metal fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: n/a
Sludge depth: 0"
Distance from top of sludge to bottom of outlet tee or baffle: 0"
Scum thickness: 0"
Distance from top of scum to top of outlet tee or baffle: 0"
Distance from bottom of scum to bottom of outlet tee or baffle: 0"
How were dimensions determined: n/a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
n/a
GREASE TRAP: _(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
n/a
Page.8 df I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 72 ISALENE WEST HYANNISPORT,MA 02672
Owner: MR. GASBARRO
Date of Inspection: 10/17/03
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX:_(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: n/a
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.):
NONE
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no): NO
Alanns in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n/a
u
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 72 ISALENE WEST HYANNISPORT,MA 02672
Owner: MR. GASBARRO
Date of Inspection: 10/17/03
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
n/a leaching pits, number: n/a
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
6' X 6' BLOCK CESSPOOL overflow cesspool, number:
n/a innovative/alternative system
Type/name of technology: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
OVERFLOW IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF
FAILURE. IT WAS EMPTY AT TIME OF INSPECTION. STAIN LINES INDICATE THE OVERFLOW HAD 1 1/2'
OF LEACHING LEFT IN IT. BOTTOM IS AT 8'2".
CESSPOOLS: X(cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: 1
Depth—top of liquid to inlet invert: 22"
Depth of solids layer: 6"
Depth of scum layer: 0"
Dimensions of cesspool: 6' X 6"'
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
MAIN CESSPOOL AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING
PROPERLY.RECOMMEND PUMPING EVERY ONE TO TWO YEARS TO PROLONG THE SYSTEM'S
USEFUL LIFE.
PRIVY: (locate on site plan)
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.):
n/a
4
Page 10 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 72 ISALENE WEST HYANNISPORT,MA 02672
Owner: MR.GASBARRO
Date of Inspection: 10/17/03
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.
i.nente all wells within 100 feet.Locate where public water supply enters the building.
✓IV
I
0
in
.Page,.l I of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 72 ISALENE WEST HYANNISPORT,MA 02672
Owner: MR.GASBARRO
Date of Inspection: 10/17/03
SITE EXAM
_Slope
_Surface water
_Check cellar
_Shallow wells
Estimated g
depth to round water 12+feet
P
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record-If checked, date of design plan reviewed: n/a
YES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators, installers-(attach documentation)
NO Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
HAND AUGER- 12+FT.
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COINB 1O.\WEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFF 8
C. DEPARTMENT OF ENVIRONMENTAL PROTE @Iv e9
ONE WINTER STREET, BOSTON ALA, 02105 (617) 292-55
TRUDI CORE
ttSecretany
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ARGEO PALL CELLtiCCI d N'Na j`94VID B SiTRUHS
Governor 1Aj. 0o sio er
6� SUBSURFACE SEWAGE DISPOSAL
A SYSTEM INSPECTION FOR '
44Q -�
WT_^ of , CERTIFICATION z
Property Address:'J'J. v_� JT Name of Owner
EU l .�N1$�tt l Address of Owner:
Date of Inspection: 05ki5\0.l� / D
Name of Inspector:(Please Print)/ .C:!-r a N� '%t�cc- U �`k'�� 1c�, I ` 4.
1 am a DEP approved system inspector pursuant to Section 15.1340 of Title 5(310 CMR 15.000) 1
Company Name: �tc vi'r.>, + F
Mailing Address: P,,;, &n a 7 -3 4 N/4G N 02,E7F 1`rA1,- �C�f
Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of 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:
41 Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: I L A Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty(30) days of
completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to ttre
system owner and copies sent to the buyer, if applicable, and the approving authority.
NOTES AND COMMENTS
S
C
fc�,OA""-J
revised 9/2/98 Page Iof11
t,*, Pnnied on Recycled Paper
ll
t ,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
"roperty Address:"jL7gINA-C �
Jwner:
Date of Inspection:
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS: c t t-�4
B. SYSTEM CONDITION
ALLY 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 complying septic tank as
approved by the Board of Health.
_ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution'pox. The system will pass inspection if(with approval of the Board of
Health).
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
_ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if (with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
revised 9/2/98 Page 2of11
I
' 1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION Icontirwed)
Property Address:
Owner:
Date of Inspection:
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if a system is failing to protect the
- public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 0 CMR 15.303(1)(b)THAT THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND AFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a It marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLI WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC H TH AND SAFETY AND THE ENVIRONMENT:
_ The system has a septic tank and soil absorption sys m (SAS)and the SAS is within 100 feet of a surface water supply or
tributary to a surface water supply.
_ The system has a septic tank and soil absorption stem and the SAS is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption ystem and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and soil absorptio system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water nalysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility a d the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine dis ance (approximation not valid).
3) OTHER
f
revised 9/2/98 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
D. SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following:
I have determined that one or more of the following failure cc exist as described in 0 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine hat will be necessary to correct the failure.
Yes No -
Backup of sewage into facility-or system component due to an overloaded o clogged SAS or cesspool.
_ Discharge or ponding of effluent to the surface of the ground or surface aters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an verloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invest or available v ume is less than 112 day flow.
Required pumping more than 4 times in the last year NOT due t 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 100 feet of a urface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of public well.
_ Any portion of a cesspool or privy is within 50 feet a private water supply well.
Any portion of a cesspool or privy is less than 1D 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, monia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the follow' g:
The following criteria apply to large systems in add' ion to the criteria above:
The system serves a facility with a design flow f 10,000 gpd or greater(Large System) and the system is a significant threat to public
health and safety and the environment becaus one or more of the following conditions exist:
Yes No
the system is within 400 feet o a surface drinking water supply
the system is within 200 fee of a tributary to a surface drinking water supply
the system is located in a trogen 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 upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further infor ation.
i
revised 9/2/98 Page 4ofII
r,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: Z 2 Z'S YZ
Owner:
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped for at least two weeks and-the system has been-receiving normal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
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.
J(� _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
TT CC 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. For example, Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
[15.302(3)(b)1
The facility owner land occupants,if different from owner) were provided with information on the proper lnaintenaacs-of
Subsurface Disposal Systems.
revised 9/2/98 Page 5of11
{
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
'roperty Address:'12—TSG-kA-*--- S7—
Owner:
Date of Inspection: .
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 3D g.p.d./bedroom.
Number of bedrooms (design): Number of bedrooms (actual)00
Total DESIGN flow a, _
Number of current residents: O
Garbage grinder(yes or no):�
Laundry(separate system) s o no If yes,separate inspection required r
Laundry system inspected ye or no)
Seasonal use (yes or no):
Water meter readings, if available (last two year's usage (gpd):
�
Sump Pump (yes or no):_ a
Last date of occupancy:--3MM&.*%4n,USWcV'w
COMMERCIAL)INDUSTRIAL:
Type of establishment:
Design flow: qpd 1 Based on 15.203)
Basis of design flow
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy:
F
GE
NERAL O
PUMPING RECORDS and source of information:
Nd
System pumped as part of inspection: (yes or no)_�L�
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
Septic tank!distribution box/soil absorption system
A_ Single cesspool
�^ Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records,if any)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed(if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)�""
revised 9/2/98 Page 6of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
'roperty Address:
Owner:
Date of Inspection:
BUILDING SEWER:
(Locate on site plan)
Depth below grade:_
Material of construction:_cast iron_40 PVC_other (explain)
Distance from private water supply well or suction line
Diameter
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(expl in)
If tank is metal, list age— Is.age confirmed by Certificate of Compliance_(Yes/ o)
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:
'omments:
(recommendation for pumping, condition of inlet and outlet tees or b les, 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_Fibergl ss _Polyethylene_other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or affle:
Distance from bottom of scum to bottom of outl t tee or baffle:
Date of last pumping:
Comments:
(recommendation for pumping, condition inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage,etc.)
revised 9/2,/98 Page7ofif
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'roperty Address:
Owner:
Date of Inspection:
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grade:_
Material of construction: _concrete_metal_Fiberglass_Polyethylene—other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm in working order:Yes_ No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet invert: _
Comments:
(note if level and distribution is equal, evidence of solids c ryover, 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) f
Comments:
(note condition of pump chamber,•condition of pumps and appurtenances,etc.)
7
revised 9/2/98 Page 8ofII _
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
4operfy Address: ? l �.�iN��
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS):
(locate on site plan, if possible; excav tion not required, location may be approximated by non-intrusive methods)
If not located, explai
n:
Type:
leaching pits, number:_
leaching chambers, number:_
leaching galleries, number:_
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:1_
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, dam soil, condition of vegetation, etc.)
58 i � �� � 6+ tit�C�I�Q�Qnt, �G�lsi nit Qw-d Cv� bQ.w V 4
No �
CESSPOOLS:
(locate on site an) t
Number and configuration: l \10kjt_\ 11 .
Depth-top of liquid to inlet invert: 3 r(o
Depth of solids layer: QS'1
)epth of scum layer:_ntl
Dimensions of cesspool: SbIA— A N
Materials of.construction:� fy�po icr,lr
Indication of groundwater:t�n
inflow (cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ondin co ition of vegetation, etc.)
tt
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.)
revised 9/2/98 Page 9of11
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'roperty Address:7Z-SsA-u,<. r
lwner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water suoply comes into house)
A
-"12 �7r}lcrv-�
G
revised 9/2/98 PAge10of11
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
ropefty Address:
Owner:
Date of Inspection:
NRCS Report name
Soil Type_ —
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water t�O
Check Cellar �0,q
Shallow wells pt&
Estimated Depth to Groundwater 315Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on'record
Observed Site (Abutting property, observation hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators, installers
XUsed USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
...ter
revised 9/2/98 Page 11of11
TOWN OF BARNSTABLE
LOCHTION � ����(`SZ SEWAGE # p
VrLLAGE eS� ASSESSOR'S MAP & LOT Z- 0 T4—
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY p
LEACHING FACILrrY: (type) (size)
`,10.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
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
c
—�' TOWN OF BARNSTABLE
LOCATIOPi 2-L�-_S��NL. S� SEWAGE #
VILLAGE W o ��V'Ml�\S d � ASSESSOR'S MAP& LOT-akiA O C
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY Wi--koq,� PV X
;LEACHING FACILITY: (type) 61%00ol(size)
-NO.OF BEDROOMS
BUILDER OR OWNER or
REW&TDATE: COMPLIANCE DATE:
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) A Feet
Edge of Wetland and Leaching Facility(If any wetlands exist N IN. Feet
within 300 fee UN �hing fci��Furnished by �2�
z
cs
Nco
-r .0
J
Q �
r