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HomeMy WebLinkAbout0198 LONGVIEW DRIVE - Health _1 99 .Longview Dive Hyannis A= 251.-144 Commonwealth of Massachusetts 7 r re Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form Not for Voluntary Assessments r - 1 198 Longview Dr. Property Address r•.t C Owner Estate of Perkins t information is Owner's Name required for every Centerville n/iK MA 02632 9/11/19 page. City/Town 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. A. Inspector Information Sl.4F-IL4 S_7 Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 City/Town State Zip Code 508.272.6433 13010 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 9/11/19 InspectiVs Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection,does not address how the system will perform in the future under the same or different conditions of use. - t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 198 Longview Dr. Property Address Estate of Perkins Owner Owner's Name information is required for every Centerville MA 02632 9/11/19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ti ® 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: 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): s t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 198 Longview Dr. Property Address Estate of Perkins Owner Owner's Name information is required for every Centerville MA 02632 9/11/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ 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): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc-rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 198 Longview Dr. Property Address Estate of Perkins Owner information is Owner's Name required for every Centerville MA 02632 9/11/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts �a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 198 Longview Dr. Property Address Estate of Perkins Owner Owner's Name information is required for every Centerville MA 02632 9/11/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth In cesspool is less I than 6" below invert or available volume is less than Y day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 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. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 i Commonwealth of Massachusetts �. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 198 Longview Dr. Property Address Estate of Perkins Owner Owner's Name information is required for every Centerville MA 02632 9/11/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts �n ,F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 198 Longview Dr. Property Address Estate of Perkins Owner Owner's Name information is required for every Centerville MA 02632 9/11/19 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): n/a Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: No engineering on file, 3 bedroom permit Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No i Water meter readings, if available (last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No 1/3/19 Last date of Date occupancy: Date t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts �. ,P Title 5 Official Inspection Form �° Subsurface Sewage Disposal System Form -Not,for Voluntary Assessments 198 Longview Dr. Property Address Estate of Perkins Owner Owner's Name information is required for every Centerville MA 02632 9/11/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft.., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: No recent pumping per owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts �. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments u 198 Longview Dr. Property Address Estate of Perkins Owner Owner's Name information is required for every Centerville MA 02632 9/11/19 page. City(rown State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known)and source of information: 1996 per BOH record Were sewage odors detected when arriving at the site? ❑ Yes ❑ No 5. Building Sewer(locate on site plan): 2'6" Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10' feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts ,F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 198 Longview Dr. Property Address Estate of Perkins Owner Owner's Name information is required for every Centerville MA 02632 9/11/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) H-10 tank appears to be structurally sound If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500g Sludge depth: 10" Distance from top of sludge to bottom of outlet tee or baffle >12 Scum thickness trace �2 Distance from top of scum to top of outlet tee or baffle >2" Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping suggested every 3yrs to prolong the life of the system t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments u 198 Longview Dr. Property Address Estate of Perkins Owner information is Owner's Name required for every Centerville MA 02632 9/11/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts 11 Title 5 Official Inspection Form �o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 198 Longview Dr. Property Address Estate of Perkins Owner Owner's Name information is required for every Centerville MA 02632 9/11/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 11 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): H-10 D-box is 30" below grade, it was excavated and is in good condition, no indication of past hydraulic failure t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 198 Longview Dr. Property Address Estate of Perkins Owner Owner's Name information is required for every Centerville MA 02632 9/11/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: C Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2, 30' ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts ,F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 198 Longview Dr. Property Address Estate of Perkins Owner Owner's Name information is required for every Centerville MA 02632 9/11/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Perf pipe trenches were video inspected and are dry at this time, no indication of past hydraulic failure 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site planj: Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts (P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �e 198 Longview Dr. Property Address Estate of Perkins Owner Owners Name information is required for every Centerville MA 02632 9/11/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts k Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 198 Longview Dr. Property Address Estate of Perkins Owner Owner's Name information is required for every Centerville MA 02632 9/11/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: hand-sketch in the area below drawing attached separately r t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 TOWN OF BARNSTABLE LOCATION SEWAGE# d VMLAGE- '� SOR'S MAP&LOT2 E5-�-1 y- INSTALLMUS NAME&PHONE NO.W4 E: 1, 041 A/SCAI !:Z7r-8 77L SEPTIC TANK CAPACITY b4-0"O LEACHING FACILITY:(type) NO.OF BEDROOMS BAR OWNER 274 me-7��4,lf tAv&,eoP PERMITDATE: COMPLIANCE DATE: 2 Separation Distance etween the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of lea4ng facility). Feet Fumished by. 44 Q cs S ti 0 C 4 Commonwealth of Massachusetts ,F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 198 Longview Dr. Property Address Estate of Perkins Owner Owner's Name information is required for every Centerville MA 02632 9/11/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: >12 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: n/a Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: 4' seperation per 1996 compliance ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: TOPO mapping shows the site at 70'msl and nearby surface water at 32'msl You must describe how you established the high ground water elevation: see above Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 s Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 198 Longview Dr. Property Address Estate of Perkins Owner Owners Name information is required for every Centerville MA 02632 9/11/19 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6(Checklist)completed ® D. System Information: For 8: Tight/Holding Tank— Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 u , COMMONWEALTH OF MASSACHUSETTS EXECUT'IVE:OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF.ENVIRONMENTAL PROTECTION i TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 198 LoicQ View.Drive vCiT MA 02632 Owner's Name:: Mar myt Isaacs Owner's Address: -Date of Inspection: Jcuze 78. 2012. Name of,Inspector: (Please Print) JamesA2 Ford Company Name: James M Ford'^ Mailing Address: P.O:13oz 49 ., Osterville,MA 02655-004W - .Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below.is true,accurate and complete as of the time of the inspection. The inspection was performed based.on my training and experience in.the proper function and maintenance of on site sewage disposal systems. I am.a?MEP­m: approved.system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000): The=system: ✓ Passes a i C nditionally Passes ` e ds Further Evaluation by the Local Approvi Author ty ai w Inspector's Signature: Date: June 20 2012 The system.inspector shall sub a copy.of this inspection report to the Approving Authority(Board of Health or DEP),within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or-greater,the inspector and the system owner shall submit the report to the.appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,.if applicable,and the approving authority.. Notes and Connnents **"This report only describes conditions at the time of insp.ectioti 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 Fonn 6/15/2000. page 1 I � 11 V Page 2 of.I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 198 Long View:Drive Centerville M,4 Owner: Margaret Isaacs Date of Inspection: June 18, 2012 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: 198 Long View Drive Centerville MA Owner: Margaret Isaacs Date of Inspection: . June 18. 2012 ` C. Further Evaluation is Required by the Board of Health: Conditions.exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment.' 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303 (1)(b) that the system is not functioning in a.manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. . System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and.soil absorption — p rp 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,perforined 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 anunonia 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 i Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 198 Lonz�View Drive Coyerville,MA Owner: _ Margaret Isaacs Date of Inspection: June 18, 2612" 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 of 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 piivy 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 fi-om pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria - are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined.that one or more of the.above failure criteria exist as described.in 310 CMR 15.303,therefore the system fails: The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large.System: To be. .considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd You must indicate either"yes".or"no"to each of the following`,. (The following criteria.apply to large systems in addition.to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the,system is within 2.00 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. . ,i Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: `198 Lori View Drive Centerville.MA Owner: Mai2aret Isaacs Date of Inspection: June 18. 2012 r} 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 7 ✓. 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., ofahe baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and 8epth of scum? ✓ Was the facility owner(and.'occupants if different from owner)provided with informatiodom 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 CVIR 15:302(3)(b)]. Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION } Property Address:. 198 Long View Drive Centerville,MA Owner Margaret Isaacs Date of Inspection: June 18, 2612 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; 1 - Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system(yes.or no): 'Nla. [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)): Unavailable Sump Pump(yes or no):. No Last date of occupancy: Currenth COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15:2.03): gpd Basis of design flow(seats/persons/sq/ft 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: Pumped 3 years ago i2er`014;ner Was system pumped as part of the inspection(yes or 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) Inhovative/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: Date of installation 512111996 per•as-built card Were sewage odors detected when arriving at the site(yes or no): No Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY,ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 198 Long View Drive Centerville 'MA Owner: Mamaref Isaacs Date of Inspection: June 18, 2012 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: 'Continents(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 confinned by a Certificate of Compliance(yes or no certificate) . ) (attach a copy of Dimensions: 1500 gal. Sludge depth`: 2" Distance from top of sludge to bottom of outlet tee or baffle; 30" . Scum.thickness: 2 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:, 101, How were dimensions determined: Measuring stick Comments,(on pumping recommendations,inlet and outlet tee or baffle condition structural integrity,liquid levels as related to outlet invert,evidence.of leakage,etc.). The tees were present. The liquid level was even with the outlet invert. There did not appear to be anE si ns 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: Continents(on_pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert, evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 198 L6nz View Drive Centerville MA Owner: Matyaret Isaacs' Date of Inspection: June 18 2012 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 swi ches,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 normal. PUMP CHAMBER: None (locate on site plan) Pumps in working order(Yes onno): , 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: 198 Long Viei•v Drive Centerville MA Owner: Margaret Isaacs Date of Inspection: June 18. 2012 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: " leaching galleries, number: leaching trenches, number, length: ✓ leaching fields, number, dimensions-, : 1 60'x4 x2'pa as-built 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 ): . There did not appear to be any signs of failure.A camera ivas used for the inspection 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: No•ne (locate.on site plan) Materials of construction: " Dimensions. . Depth of solids: Continents(note condition of soil signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 i Page 10 of 11 OFFICIAL INSPECTION FORM: NOT FOR VOLUNTARY ASSESSMENTS` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Addrew 198 Lou View Drive .Centerville.MA: Owner: Mar Qar et Isaacs Date of Inspection: June 18 2012 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. BA6k a o o � 3 s� ag 3 a 1p . Page I of I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 198 Long View Drive Centerville MA Owner: _ Mai-Qaret Isaacs Date of Inspection: June 18 2012 SITE EXAM Slope Surface water .Check cellar Shallow wells Estimated depth to ground water 40+1- feet Please indicate (check) all methods used toi:determine the high ground water elevation: Obtained from system design plans on record= if checked, date of design plan reviewed: Observed site(abutting h ole.within 150 feet of SAS) $ ✓ Checked with local Board of Health-ezplain:. Tovogiwyhic and water contours mays Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how,you established the'high ground water elevation: _Usinjz Barnstable tobo&aphic and water contours maps the mays were showinjz approximately 40 +/ to ground water at!his site. This report has been prepared.only for iihe septic systent and components described herein. This septic system has been inspected and passed as of the date of inspection. This report is not a warranty or•.guarantee that the system t-vill function properly in the f.rttrr•e. There have been.no warranties oil guarantees, either expressed, written or in'lied, relating to the septic system, the inspection; this report and/or any.cornpor.ents,of the septic system which have not been located and inspected: .: ;li • , �j TOWN OF BARNSTABLE LOCATION IRO I OAC V l eAJ \cJ r- SEWAGE# VILLAGE O.L6 j 6fV,I�L ASSESSOR'S MAP&PARCEL o^15(' ttY INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY Sn LEACHING FACILITY:(type) (0 0 ' I—GA G^ (size) (o x Yx a NO. OF BEDROOMS 3 OWNER t SIgACS PERMIT DATE: 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 GGTj on J. 0r� aa�- A aACk a aoo ' 3 Q I SG a8 a yq 3a 3 Sl ya Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 198 Longview Drive Property Address Richard McFarland Owner Owner's Name information is required for Hyannis MA 02601 October 21, 2009 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information forms on the " computer,use 1. Inspector. only the tab key to move your David D. Coughanowr cursor-do not Name of Inspector use the return key. Eco-Tech Environmental Company Name . 43 Triangle Circle` Company Address Sandwich MA 02563 City/Town State Zip Code 508 364 0894 1328 Telephone Number License Number B. Certification certify that l have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Z7 � P— October 21, 2009 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer;.if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. L� � V t5ins•09/08 Title 5 Official Inspection Form: bsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 198 Longview Drive Property Address Richard McFarland Owner Owner's Name information is required for -Hyannis annis MA 02601 October 21, 2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR. 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if the inspector cannot answer Yes to any of the failure criteria listed in Section D on pages 4-5 of this report. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. 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 Form: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 °M 198 Longview Drive Property Address Richard McFarland Owner Owner's Name information is required for Hyannis s MA 02601 October 21, 2009 every page. City/Town State" Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to,a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced F1, Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): p ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation,is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt:marsh t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 198 Longview Drive Property Address Richard McFarland Owner Owner's Name information is required for Hyannis MA 02601 October 21, 2009 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 198 Longview Drive Property Address Richard McFarland Owner Owner's Name information is required for Hyannis MA 02601 October 21, 2009 every page. Cityrrown 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. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water,supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of.custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area.-IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. _ t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 L Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 198 Longview Drive Property Address Richard McFarland Owner Owner's Name information is required for -Hyannis annis MA 02601 October 21, 2009 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the followinghave been done. You must indicate"yes" or no" as to each of the following: Y 9 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): n/a Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a-no plan t5ins-09/08 Title 5 Official Inspection 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 M 198 Longview Drive Property Address Richard McFarland a• Owner Owner's Name information is required for Hyannis i,a: JMA 02601 October 21, 2009 _ every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 3 Does residence have a'garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?•[if yes separate inspection required] ❑ Yes ® No° Laundry system inspected? ❑ Yes ❑ No Seasonal use? !. ❑ Yes. ® No Water meter readings, if available last 2 years usage d 159 gpd 9 ( . Y 9 (gpd)): Detail: $ 2007-2008 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?t ❑ 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•09108 *Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 198 Longview Drive Property Address Richard McFarland Owner Owner's Name information is required for Hyannis MA 02601 October 21, 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 198 Longview Drive Property Address Richard McFarland Owner Owner's Name information is required for Hyannis MA 02601 October 21, 2009 every page. Cityrrown State Zip Code Date of Inspection •I). System Information (cost:) Approximate age of all components, date installed (if known) and source of information: Age: 13+ years. Disposal Works Permit issued 5/21/96 (Permit#96-205) Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site.plan): Depth below grade: 2 feet Material of construction: cast iron ❑40 PVC '❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): No evidence of leakage or backup into dwelling was observed. Septic Tank(locate on site,plan): A Depth below grade: 1 feet Material of construction: ® concrete ❑ metal. ❑ fiberglass ❑ polyethylene ❑ other(explain) ` If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No • Dimensions: 10.5 ft x 5 ft x 5 ft(1500 gallon) Sludge depth: 5 in t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 198 Longview Drive Property Address Richard McFarland Owner Owner's Name information is required for Hyannis MA 02601 October 21, 2009 every page. Citylfown 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 in Scum thickness 3 in Distance from top of scum to top of outlet tee or baffle 8 in Distance from bottom of scum to bottom of outlet tee or baffle 13 in How were dimensions determined? As built card Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping not required at this time but maintenance pumping is recommended within and every two years. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. Grease Trap (locate on site plan): Depth below grade: 1 feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 198 Longview Drive Property Address Richard McFarland Owner Owner's Name information is required for Hyannis MA 02601 October 21, 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): r ' Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal D fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition.of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 198 Longview Drive Property Address Richard McFarland Owner Owner's Name information is required for Hyannis MA 02601 October 21, 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box if resent must be opened) locate on site plan): ( p P ) ( p ) Depth of liquid level above outlet invert at outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box appears structurally sound with no evidence of leakage in or out. Some solids in sump. No effluent contact staining was observed above the normal operating level of distribution box. 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 Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 198 Longview Drive Property Address Richard McFarland Owner Owner's Name information is required for Hyannis MA 02601 October 21, 2009 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Type ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 1-60 ft ❑ 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.): . , Soils above leaching trench appeared unsaturated. No evidence of.surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. An observation hole was dug into leaching trench stone and no effluent contact staining was observed in the stone or overlying soils. No standing effluent was observed to a depth of 8 in below the peastone layer. 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 198 Longview Drive Property Address Richard McFarland Owner Owner's Name information is required for -Hyannis annis MA 02601 October 21, 2009 every page. Citylrown 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-'age 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °w 198 Longview Drive Property Address Richard McFarland Owner Owner's Name information is required for Hyannis MA 02601 October 21, 2009 every page. Cityrrown 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 10 0 - I ' \ c6 t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17' Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 198 Longview Drive Property Address Richard McFarland Owner Owner's Name information is required for -Hyannis annis MA 02601 October 21, 2009 every page. Cityrrown 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: Barnstable GIS Department records You must describe how you established the high ground water elevation: Town of Barnstable GIS Department records indicate that the property is over 30 feet above groundwater table. Before filing this Inspection Report,, please see Report Completeness Checklist on next page. t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 198 Longview Drive Property Address Richard McFarland ` Owner Owner's Name information is required for Hyannis MA 02601 October 21, 2009 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 t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17