HomeMy WebLinkAbout0041 LINDA LANE - Health 41 Linda Lane
Hyannis
A= 248-215
I
f�
OUpVf##DOVdMS?AMM a
UNim"ornmWLS03W IDS
3i11?4 mm4 m m om
G S
g°�ono�S'r
ysn ul eps- l v upoo, eatus
ma poll
moss 'AN,
i
'I
0
_y ti
TOWN OF BARNSTABLE
LOCATION T f )A 2,4 SEWAGE #
VILLAGE �4y4M IS ASSESSOR'S MAP & LOT!?R I S—
INSTALLER'S NAME&PHONE NO.
SEPTIC.TANK CAPACITY UUD
LEACHING FACILITY: (type) R 7 (size)
NO.OF BEDROOMS 3 N
6
BUILDER OR OWNER Alkows
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�acility) // Feet
Furnished by �/i sl tOn t'0/
co
Ton) r . .
-- , Q ► O rh
d co en 'w
13
rb
µ..
'LO;A-CiO ; (miA S1=AVAGE _
VU-L .GC.- ASSESSOR'S MrjP & LOTA
INSTA.LLER'S NANUE&PHONE NO.
Sc_PTIC TANK CAPACP'Y ®�� -___--- -----_
I EiCYEUNG F.4CiL.I1Y: (type) _— --_-- (size) _ _ .
NO. OF BEDROGMS_
BUILDER OR OWNER
-TDATE: ,COM.PLIAiv'CE DATE:
Separation Distance Between che:
Maximum Adjusted Groundwater Tabu-to the Bottom of i ea:,ir,c raciiity
P,ivatc Water Supply Well and Leaching Facility (If any wells exist �y
on site or within 200 feet of leacl'cim- facility)
Edge of Wetland and Leaching Facility X any wctl nd ezi ;
i within aid)fee:of(caching Licib;r;i _-`--
r,!;
7
T
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
41 LINDA LN
Property Address
BUCZEK
OwnerOwner's Name/
information is �n
required for n�_J. MA 02632 10/30/09
every page. City own' 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.
p°'l"t When filling out A. General Information
W
forms on the
computer,use
1
only the tab key . Inspector:
to move your DOUGLAS A BROWN
cursor-do not use the return Name of Inspector
key. DOUGLAS A BROWN INC
Company Name
P.O. BOX 145
Company Address 0
CENTERVILLE MA 02632
City/Town State Zip Code
508-420-4534 S14297
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
CM ❑ Needs Further Evaluation by the Local Approving Authority
c�s3 c
10/30/09
co — .Mlnsplr&orAignature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
Health or DEP)within 30 days of completing this inspection. If the system is a shared system or .
O El t;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•09M Title 5 Official Inspection Form:Subsurfa ewa a Dis sal g po m•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
41 LINDA LN
Property Address
BUCZEK
Owner Owner's Name
information is CENTERVILLE
required for MA 02632 10/30/09
every page. Cityrrown 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:
® 1 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:
PIT HAS ONLY A SMALL AMOUNT OF WATER AT THIS TIME
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•09108 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
41 LINDA LN
Property Address
BUCZEK
Owner Owner's Name
information is CENTERVILLE required for MA 02632
Date
Ins
09
of ns
every page. Clty/Town o
State Zip Code D Date pection
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):
i
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•09108
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
f ,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
41 LINDA LN
Property Address
BUCZEK
Owner Owner's Name
information is CENTERVILLE required for MA 02632
dy/Town Date of 09
every page. C
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 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 dogged SAS or cesspool
El ® 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
gins 09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y 41 LINDA LN
Property Address
BUCZEK
Owner Owner's Name
information is CENTERVILLE required for MA 02632 10/30/09
every page. Clty/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.
❑ ® 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 CM 15.304.The system owner should contact the appropriate
regional office of the Department.
t5ins•09/08
Title 5 Official Inspection Form:Subsurface Sewage Dsposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
41 LINDA LN
Property Address
BUCZEK
Owner Owner's Name
information is CENTERVILLE required for MA 02632 10/36/09
every 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
t5ms•09,D8 Title 5 Official Insp
ection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
41 LINDA LN
Property Address
BUCZEK
Owner Owner's Name
information is CENTERVILLE required for MA 02632 10/30/09
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
ACCORDING TO AS-BUILT CARD SYSTEM CONSISTS OF A 1000 GALLON TANK D-BOX AND
LEACH PIT
Number of current residents: 2
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 years usage(gpd)): 07-163 08-192
Detail:
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•09/08
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
a� 41 LINDA LN
Property Address
BUCZEK
Owner Owner's Name
information is CENTERVILLE required for MA 02632 10/30/09
every page. Clty/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:
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
41 LINDA LN
Property Address
BUCZEK
Owner Owner's Name
information is CENTERVILLE required for MA 02632 10/30/09
every page. Cltylrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed(if known) and source of information:
APPEARS TO BE ORIGINAL
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade:
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.):
Septic Tank(locate on site plan):
Depth below grade:
feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑ polyethylene
El other(explain)
1f tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
3"
t5ins•09/08
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
sY 41 LINDA LN
Property Address
BUCZEK
Owner Owner's Name
information is
required for CENTERVILLE MA 02632 10/30/09
every page. Cityrrown
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 29"
Scum thickness 6"
Distance from top of scum to top of outlet tee or baffle 5
Distance from bottom of scum to bottom of outlet tee or baffle 11
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
El 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
t5ms•09N8 Title 5 Official Inspection Form:Subsurface Sewage Disposal posal System•Page 10 of 17
i
Commonwealth of Massachusetts
Am,wk Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
41 LINDA LN
Property Address
BUCZEK
Owner Owner's Name
information is CENTERVILLE required for MA 02632 10/30/09
every page. Cltyfrown 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
t5ms-09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
41 LINDA LN
Property Address
BUCZEK
Owner Owner's Name
information is CENTERVILLE required for MA 02632 10/30/09
every page. Cftylrown 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"
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.):
BOX LOOKS TYPICAL FOR ITS AGE WITH SOME CORROSION
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•09/08 Title 5 Official Insp
ection 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
'Y 41 LINDA LN
Property Address
BUCZEK
Owner Owner's Name
information is
required for CENTERVILLE MA 02632 10/30/09
every page. Cltyrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
PIT WAS ALMOST DRY AT THIS TIME STAIN LINE AROUND 1 FT FROM BOTTOM
Cesspools(cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-09)GB
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
It41 LINDALN
Properly Address
BUCZEK
Owner Owner's Name
information is CENTERVILLE required for MA 02632 10/30/09
every page. Clty/Town 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:
Dimensions
Depth of solids
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disp
osal posal System•page 14 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�( 41 LINDA LN
Property Address
BUCZEK
Owner Owner's Name
information is CENTERVILLE required for MA 02632 10/30/09
every page. Citylrown 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
I
t5ins•09/08 Title 5 Official Insp
ection Form:Subsurface Sewage Disposal System•Page 15 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
41 LINDA LN
Property Address
BUCZEK
Owner Owner's Name
information is CENTERVILLE required for MA 02632 10/30/09
every 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: 30+
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
OFF PREVIOUS INSP REPORT DATED MARCH 30 2004 BY JAMES FORD
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of V
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'( 41 LINDA LN
Property Address
BUCZEK
Owner Owner's Name
information is CENTERVILLE required for MA 02632 10/30/09
every 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
tins•09A8
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
// TOWN OFBARNSTABLE
LOCATION (�/U—
SEWAGE #
VILLAGE 14V4f 11 IS
ASSESSOR'S MAP& LOTC y I S—
INSTALLER'S NAME&PHONE NO. #
SEPTIC TANK CAPACITY. 1!/l,1p
1
LEACHING FACILITY: (type) I'i 1 (a X(n
(size)
NO. OF BEDROOMS 3 I I
BUILDER OR OWNER Sre /l le. �t✓l OwS
PERMIITDATE: 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)
Edge of Wetland and Leaching Facility (If any wetlands exist Feet I
I
within 300 feet of leaching acility)
Furnished b /1 S/�Cu"1 tpr� Feet
y— � Ford
i ay 3 t� p p
a a•y� 31 a 3 j
6 � y
3 aL a-1
f
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
MAP 24 g
PARCEL,
LOT
TITLE 5
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 41 Linda Lane
Hyannis, MA 02601
Owner's Name: Stephanie Pelkowsky
Owner's Address:
�w
Date of Inspection: March 30, 2004
Name of Inspector: (Please Print) James M. Ford �c
Company Name: James M. Ford
Mailing Address: P.O. Box 49 < . t
Osterville,MA 02655-0049 co
N c„e
Telephone Number: (508)862-9400 z
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the' formati4;rrepqwrted
below is true,accurate and complete as of the time of the inspection. The inspection was perforrr ed basePon m fn
training and experience in the proper function and maintenance of on site sewage disposal syst s. I am a DEP
approved system inspector pursuant to Section 15.340 of Tltle 5(310 CMR 15.000). The system:
✓ Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Faiks
Inspector's Signature: Date: April 4, 2004
The system inspector shall subLa 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 I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 41 Linda Lane
Hyannis, MA
Owner: Stephanie Pelkowsky
Date of Inspection: March 30, 2004
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: 41 Linda Lane
Hyannis, kM
Owner: Stephanie Pelkowsky
Date of Inspection: March 30, 2004
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.
L 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
— Y eP rP Y (SAS) 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: 41 Linda Lane
Hyannis, AM
Owner: Stephanie Pelkowsky
Date of Inspection: March 30, 2004
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
lam•
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: 41 Linda Lane
Hyannis, MA
Owner: Stephanie Pelkowsky
Date of Inspection: March 30, 2004
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 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 41 Linda Lane
Hyannis, MA
Owner: Stephanie Pelkowsky
Date of Inspection: March 30, 2004 ,
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: 0
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): Yes and weekend use
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Unknown
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: Unavailable
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: Qallons--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:
Installed 1119193-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: 41 Linda Lane
Hyannis, AM
Owner: Stephanie Pelkowsky
Date of Inspection: March 30, 2004
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: 20"
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: 1000 gal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
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: 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.):
Tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage.
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 I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 41 Linda Lane
Hyannis, MA
Owner: Stephanie Pelkowsky
Date of Inspection: March 30, 2004
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 was level. No solids were present.
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: 41 Linda Lane
Hyannis, MA
Owner: Stephanie Pelkowsky
Date of Inspection: March 30, 2004
SOIL ABSORPTION SYSTEM(SAS): . ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 1 -6'x 6'(1000 gal.)
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
Innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil, condition of vegetation,etc.):
The pit was dry. The scum line was approximately 1'up from the bottom. There did not appear to be anv signs of failure. The
cover was 2'below grade. The bottom to grade was 81
.
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.):
i
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: 41 Linda Lane
Hyannis, MA
Owner: Stephanie Pelkowsky
Date of Inspection: March 30, 2004
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.
J
I I
►A 4
a aye 31
10
Page 11 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 41 Linda Lane
Hyannis, MA
Owner: Stephanie Pelkowsky
Date of Inspection: March 30, 2004
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 30' +/- 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 ground water elevation:
Using the Barnstable topographic map and the Cape Cod Commission water contours map,the maps were showing approximately
30'+/-to ground water 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
Co.Nj�. 10.NWEALTH OF ALkSSACHUSETTS
EXECUTIVE OFFICE OF EN—VIRON', N ME. TAL ASP.A;
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE STREET. BOSTON Ntk 0210E (6171 292-1,5.iotl RECE,VE9
J OCT 2 8 1999 -0,
DY C.
e" 701MOFggpp Secret.
DEPF
STP.*-'.
ARGEO PAUL CELLUCCI D B Commis:s:
Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 9
qqRv— PART A
yv CERTIFICATION
Property Address: Name of Owner CIA t
Dine of Inspection:. Address of Owner: 9_So
Name of Inspector:(Please Prim)H Oz.19
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 1310 CMR 15.000)
CAmTspanyName: 42YCA�i`r I .
Maiing Address:-Z� A'n 4 .7 4"'01 '=)2-C4IC7
Telephone Number: 4 -:1 ) (44 7 Z,- e—_C=L_
CERTIFICATION STATEMENT ad below is,true. accurate
i certify that I have personally inspected the sewage disposal system at this address and that the information report
and complete as of the time of inspection. The inspection was performed based an my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
Conditionally Passes
Needs Further a MI , y the al Approving Authority
Falls
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 thirty (30) days c
completing this Inspection. It the system is a shared system or has a design flow of 10.000 qpd or greater.the inspector and the system own,
shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to
ttrr
system owner and copies sent to the buyer.if applicable. and the approving authority.
NOTES AND COMMENTS
revised 9/2/98 pace i or ii
V..- P,wrd on R"k-d Pipe,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
'roperty Address: l L(/vC
Jwner:
Date of Inspection:
INSPECTION SUMMARY: Check A, A C, of 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:
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.
Indicate yes, no, or not determined(Y. N, or NO). 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; c,
the septic tank, whether or not metal, is cracked. structurally unsound, shows substantial infiltration or exfiltration, or tan,
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:
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 replaced -
_ The system required pumping more then 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 ps e2or11
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
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 the system is failing to protect the
public health, safety and 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 THE PUBLIC HEALTH AND SAFETY 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 salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH( D PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE P BLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil abs ption system (SAS)and the SAS is within 100 feet of a surface water supply cr
tributary to a surface water supply.
The system has a septic tank and soil a sorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil sorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soi absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a ell water analysis for coliform bacteria and volatile organic compounds indicates tha, the
well is free from pollution from tha facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to det mine distance (approximation not valid).
3) OTHER
r
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 conditions exist s described in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacte to determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facility or system component due to n overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the gro d or surface waters due to an overloaded or clogged SAS cr
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 Inver/r available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last y ar NOT due to clogged or obstructed pipelsl.
q P 9
Number of times pumped_.
Any portion of the Soil Absorption System, ce spool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 00 feet of a surface water supply or tributary to a surface water supply
Any portion of a cesspool or privy is withi a Zone I of a public well.
_ Any portion of a cesspool or privy is wit in 50 feet of a private water supply well.
Any portion of a cesspool or privy is I s•than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If he well has been analyzed to be acceptable, anach copy of well water analysis fcr
coliform bacteria, volatile organic co pounds, ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No- to each of he following:
The following criteria apply to large syst s in addition to the criteria above:
The system serves a facility with a des gn flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public
health and safety and the environmen because one or more of the following conditions exist:
Yes No
the system is within 40 feet of a surface drinking water supply
the system is within 2 0 feet of a tributary to a surface drinking water supply
the system is locate 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 s tem shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further ' formation.
revised 9/2/98' pyFceorn
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
r'roperty Address:
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.
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. For example, Plan at B.O.H.
_ Determined in the field (it any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
115.302(3)(b)I
The facility owner (and occupants,if differeru from owner) were provided with information on the propermaintena—e-of
SubSurface Disposal Systems.
revised 9/2/98 Page ofII
a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART C
SYSTEM INFORMATION
'roperty Address: %
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: g.p.d./bedroom.
Number of bedrooms (d esiQ):�3 Number of bedrooms (actual s
Total DESIGN flow
Number of current residents: 0
Garbage grinder(yes or no):P
Laundry(separate system) ( es or no):�: If yes, separate inspection required
Laundry system inspected j or nol
Seasonal use (yes or no):t2
Water meter readings, if available (last two year's usage(gpd):
Sump Pump (yes or no):—L1--V
Last date of occupancy: k W((. WV-1
COMMERCIALfINDUSTRIAL:
Type of establishment:
Design flow: gpd 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:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part 8f inspection. (yes or no)_
If yes, volume pumped: gallons
Reason for pumping:
TYP£OF SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) lif 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 lif known) and source of information: -tom -7 it S
Sewage odors detected when arriving at the site: (yes or no)p�b
revised 9/2/98 Pace 6ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
r1 / SYSTEM INFORMATION(continued)
'roperty Address:
Owner:
Date of Inspection:
BUILDING SEINER: A , l
(Locate on site plan) 0
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:-*.s
(locate on site plan)
Depth below grader
Material of construction:AConcrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is metal, list age_ Is age confirmed by Certificate of Compliance_(Yes/No)
Dimensions. upc IA-
Sludge depth::h
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:_ II
Distance from top of scum to top of outlet tee or baffle: �k t(
Distance from bottom of scum to bottom of outlet t or baffle:-A,�
How dimensions were determined:
;omments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid leve4n rlelatio�o outlet invert, stlrJu tvrel integr" .
evidence,of leakage,etc.) '
vj U '
GREASE TRAP:-3
(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 9/2/98 Pare 7ofII
-r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
(� SYSTEM INFORMATION (continued)
'roperty Addres
Owner.
Date of Inspection:
TIGHT OR HOLDING TANK: ' u (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_otherlexplain)
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 BOXI
(locate on site plan)
Depth of liquid level above outlet invert:J��U�S/
Comments:
(note if level and distnb o is ual, evidence of olids carryoy�r, evid ce of lea ge int or out of box, etc.) -
i� (� c�Q ��� v� yczs� . 5 �T 1 t��
PUMP CHAMBER: L"�
(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 9/2/98 PagcItorit
I
c l 1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (corrbnued)
,ropeny Address:
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, explain:
Type:
leaching pits, number:—ILW
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, igns of hydraulic failure, level of ponding. mp 'I, co 'lion of vegetation CX e'VIA ttc.) G
/ILie
O S
CESSPOOLS`.V�4D
(locate on site plan)
Number and configuration:
Depth top of liquid to inlet invert:
7epth of solids layer:
)epth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:[J�
(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 9/2/96 Pilgc9ofII
.,,,SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
:.,.PART C
SYSTEM INFORMATION (continued)
'roperty Address:
Jwner:
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 supply comes into house)
l Z 3 tI
revised 9/2/98 r.getoortt
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
A SYSTEM INFORMATION (continued)
roperty Address: C,
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-)0
Check Cellar Vyt-"
Shallow wells /Jd
Estimated Depth to Groundwater 'fleet
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
ls"u
USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
0 L
revised 9/2/98 Pagc11of11
FEB...... b............
APPROVED THE COMMONWEALTH OF MASSACHUSETTS
Barnstable Conservation Department BOARD OF HEALTH
ign� /-Dew 3-T OWN OF BARNSTABLE
, pphratinn for Diripwial, Work,i Tomitrnrtinn 11amit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
Sys at:
N�
� ,, tc:�tion•:�ddress or Lot No.
------------
�s acr Ad s
a --------- �.... .�...._�......� - � x = 1 /�................................�.
--_..... ..
Installer Address
Type of Building Size Lot...........:................Sq. feet
�., Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
a' 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--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date.........................................
,� Test Pit No. I----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................
LZ Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
pr ----------------------------------------••--------------•----------•----•••-----•-•--------....................................-•----•--•-....---------.-•---
ODescription of Soil........................... •--•---•-•-----••-•------•------........----•-------------------------------...-----------...-•------------...---•-----•----•-----•---.••---
x
x -----------------------------------------------------------------------------------------•----•-------------. ------ ( l `
U Nature of Re r nr Alterations—Answer when applicable._� o.. t..../. ... '.........
-•-------------- --------•------------------------•--............._......------------ ...................................... ------....------------------....---------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has cued y th o heal
Signe .......... ....
Dare
Application Approved By .......... � .'D.. ` ......... Lt.......�..-./3
Application Disapproved for the following reasons: ..... .... ......... ............. ..................................................- ................. ---. .
..................... ............ . ........ .. ....................................... . ...................... . .
q Dare
Permit No. ! �-- -4�?3...................... Issued .........................................................
Dare
i-tiF+%-tip`f^ .:... ::�:L•r�.J r r v ��,� �jtw i.L
V J
NO....?.. 3..' ?3 r��r Fss............0...........
THE COMMONWEALTH OF MASSACHUSETTS
�� BOARD OF HEALTH V,
`/ -s 53'TOWN OF BARNSTABLE
` Xpli iratiutt for Di►ipwm`i urttu C uttutr cttun ermtt
Application is hereby made for a Permit to Construct ( ) or Repair (---)individual Sewage Disposal
System at: qr�
oc ctinn address or Lot No.
i •::_......_lr ------------------------------------------------------ -------------------------------------•----------------.........--------------------..............
', +�snec Address
w -�'P,uJ� G1t,`�-I!• C�l� ,� _.__x�y� /I�• �rG� /s, /r1� GZ�S/�
� Installer Address/
UType of Building Size Lot............................Sq. feet
►� Dwelling— No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
alOther fixtures ............... ..•._..._..........------....:---------------------------------------- -----------------• '•---------•-•----•..._--------..........
Q
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.
3 Seepage Pit No--------------_--.-- Diameter---------- .-- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by ----........••-•••••--•----•----------------•--•--------•--_.... Date-.......................................
14 Test Pit No. I................minutes per inch .Depth of Test Pit.................... Depth to ground water........................
44 TestlPit No: 2................niinutes,per inch Depth of Test Pit.................... Depth to ground water........................
R'
0 Description of Soil............................................................•-•-•--•--•--••---------- -----------------....--------•---------....---•--•-----•-•--............._....
U
W
x ........................................................_...-•------------------•--...-----•--•...a......... ---------------- ---- ---....--
U Nature of Repairs or Alterations—Answer when appl ble..l moo....�A. ......�� ..f.._.���U_:- _..-..••..
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has beeeenn issued y the board othhee'a`lth! f I_
Si ned� \ ��' ��L ..............5:5:5 \ J J
S. g .............; ............ . .............. ......r ......
Dace
re
Application Approved By .............. .. .. r- .......................:. - .1.-.-. ..-.����.
l Application Disapproved for the following reasons: .........._........._............... .. ........................... ...................................................
.................. .......................... ........ ............ ....... ......................... . ........................................-- . -- --.. .. --- ...........................
q Dace
Permit No. �----�.------------------- Issued .....................-....
l..
Dace
THE COMMONWEALTH OF MASSACHUSETTS t
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate of C�omptianee
THIS IS TO CERTIFY,, That the Individual Sewage Disposa296-1
stem constructed ( ) or Repaired
by ......................... bhy�r---�.9 l(c./�CL�---C!l/)-IfS .= .._.......... --------- ---
�l/ klr�_&q....... _ -Ark:.:_ .............. f-t��-- ----------.....................----.....----------------.-----------
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. _---..��..��_- j�.G?.3..... dated .. .. II
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. c� �\
DATE.........__1.!.-....r..".- ........... ..._...__....._......- _...... Inspector ....-----.....1...:...�'' ..
d
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No.. // G TOWN OF BARNSTABLE
�.�a. 3......... FEE. -�- •-•.-....
Dispsal urku Tutmtrutw' nt f rrmit
Permission is hereby granted....t� r�I.•-` a - �G�f�Cd C �f c ......•--------------------••-- .
to Construct ( ) or Repair (_,.fan Indiv/idual Sewage Disposal System, �Y /L+ �
Street /
as shown on the application for Disposal Works Construction Permit No./�-AP_3. Dated...........................................
--
'....
/
DATE.................`-I-- --�-- -1 e1--
Board of Health
FORM 36508 HOBBS ac WARREN.INC..PUBLISHERS
C, TOWN OF BARNSTABLE
4 ,
'LOCAhON41 LjnJR (,14j-2 • SEWAGE #q,J &(D3
VILLAGE 17`f ASSESSOR'S MAP & LOT 15'
.INSTALLER'S NAME & PHONE NO .4
SEPTIC TANK CAPACITYJOf:�O q6V ttL
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER Aol may"
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
-xV
r
:5o z
'Y
f
_4.
C.'