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HomeMy WebLinkAbout0170 MITCHELL'S WAY - Health 170 Mitchell's Way Hyannis P 290 140 a� i TOWN OF BARNSTABLE ,V LOCATION 17,1) 1` ell -,� SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER 414Z4,0 PERMITDATE: -7- COMPLIANCE DATE: Z d Separation Distance Between.the: ° Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist. on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching.Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 'I - O n Ca 140�r 6 0.� r COMMONWEALTH OF MASSACHUSETTS n St,, LE EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS ?? DEPARTMENT OF ENVIRONMENTAL PROTECTION " ! ' . n TITLE S OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A nn CERTIFICATION Property Address: /t/ i C 4"Zr G/q AR n + Odd-O/ Ar;RCEL ; Owner's Name: Owner's Address: , (O k�A 1' a✓ii a 6p Date of Inspectio: 9 o F. Name of Inspector.Wican print) r-Ir— /—•Ik Company Name: iYl/i • -- cG Mailing Addmaa: o.x is Telephone Numbers rowCERTIFICATION STATEMENTI 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 sews a diapproved s ystem ins g sW�systems I am a IIEPpector pursuant to on ISJ40 of Title 5(310 CMR 15.004 The systemsesPasConditionally Passes' Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: / Date: S60c 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 ipspectioa If the system is a shared system or has a design flow of lo,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional o@'ice of the DEP.The original should be sent to the system f applic owner and copies sent to the buyer,iable,and the approving authority. Notes and Comments *"*'This report only describes conditions at the time of ins pection and under the conditions of use at that time,This ip9pSCtinu do"not addre.m how the tyytcm will perform in the future under the flame or different conditions of use. 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: / pit Owner: /u n ro Date of Inspection: 9 / Inspection Summary: Check A,$,C,D or E!A Alj,�complete an of Sectioa D A. Syste asses: I have not found any inforn ation which indicates that any,of the failure criteria described in 310 CM 15.303 pr in 310 CMR 15304 exist.Any failure criteria not evaluated are indicated blow. Comments; B. System Conditionally Passes: r One or more system cotrponents as described in the"Conditional Pass"section need w t ` repaired. The system,upon completion of the or re o b repbace pair,as approved by the Board of Health,will pass. Answer yes,noo or not determined(YXND)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 exfiltmdon 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 Wucturaily soiU4 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 brokeq 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).'Tile system will pass inspection if(with approval of the Board of Health): broken pipes)are replaced obstruction is removed ND explain: page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: /0 �./C G 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 is fa:Lngto public4uWth,safety or theenvironment.is L System will pass unless Board of Health determines in accordance with 3to CMR M303(1)(b)that the system is net Amedooing in a n er which will Pretest public Jwakh,-Wets and the eavi t: Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wind or a salt marsh 2. System will fail unless the Board of Health(and Pubilr 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'taak and soil absorption system(SAS)and the SAS is within 100 feet of a surface a'at"supply or tributary to a surface water supply. The system has aseptic 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 Pnvatc water supply well**.Method used to detestm a distance **This system passes if the well water analYs*performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well isfree 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; Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) PzMwrty Address: 120 /W/'/ � c G�aM✓1/S � �yf Date of Thaspection: D. System Failure Criteria apptieahle to all�ygtema: You must indicate"yes"or"W to each of the following for all inspections: Yes No/ ll// P Of sewage into facility or system component due to overloaded or clogged SAS or cesspool jDischarge or ponding of e8luettt to the surface of the ground or surface waters due to an overloaded Or ogged SAS or Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or _ :E��lqu'd depth in cesspool is less than 6"below invert or available volume is less than''/z day flow meted 1�1�g more than 4 times in the last year NOT due to clogged or /of times pumped °g8 obstructed pipe(s).Number _ V Any portion of the SAS,cesspool or privy is below high ground water elevation portion of cesspool or privy is within 10)feet of a surface water supply or tributary to a surface water supply, r 0. — portion of a cesspool or privy is within Tine 1 of a public well. portion of a cesspool or privy is within 50 feet of a private water supply well. _ T Amy portion of a cesspool or privy is less than 100 feet but lr 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 nitrogen and nitra ppm te nitrogen is Mal to or less than S presence of ammonia are triggered.A copy of the analysis must be attached s provided that no other failure criteria to this torn.} (YeslNo)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CNM 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 L Large Systems: To be considered a large system:tlse system must serve a gpd facility with a design flow of 10,0011 gpd to 15,000 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 system is within 400 feet of a surface drinking water supply r e the system is within 200 feet of a tributary to a surface drin_lcng water supply - the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—I WPA)or a mapped ,V are it of a public water supply well If you have answered"yes"to any question in Section E the system is considered a si "Ycs" in Section D above the largeSystem hner �syste threat, answered sY m_its • significant threat under Section E or failed under Section Dwshall upgrade operator of any Large system considered a 15.304,The system.owner should contact the a p&ade system m accordance 310 C1�rR appropriate regional office of the Department, 6 C4,1- ) r Page S of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAG E DISPOSAL SYSTEM INSPECTION FORM PART B n CHECKLIST Property Address: 4// Vc, v� .4 to Owners Date of Inspection: Check if the following have been done.You most indicate es"or"no"as to each of the followin Yes No —/Pu-Ong information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeds _ rHave system received normal flows in the previous two week period _ rveNeh mes of water been_introduced to the system recently or as part of this inspection Were as-built plans of the t / system obtained and examined?(If they were not available note as N/A) l/ Was the facility or dwelling inspected for signs of sewage back up Was the-site inspected for signs of break out !/ Were all system componeem excluding the SAS;located on site _ Were the septic tank manholes uncovered, and the' Of the or tees,material of opened, mtenor of the tank inspected far the condition construction,dimensions,depth of liquid depth of sludge and depth of scum 9. Was the facility owner(and occupants if different from owner)provided with information on the maini�nce of�sewage systems The see and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no g information.For example,a plan at the Board of Health. _ Determined in the field(if any of the faihue criteria related to Part C is at issue approximation of distance'a is unacceptable)P 10 CN R 15.302(3)(b)] t I w page 6 of i 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: ` �v /-J�i 7"c �A'C Gin Owner:�a w Date of inspection: o ItESIDhN17AL FLOW CONDITIONS Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CUR 15.203(for example: 110 gpd x#of bedrooms):=-p Number of current residents: O Does residence have a garbage grinder•(es or no): D Is laundry on a separate sewage system(Yes no):�[if es La'�Y system inspected(Yes or no): Y te inspection required) Seasonal use:(yes or no): f ' Water meter readings,if available(last 2 years usage(gpd)): Sump pump(Yes or no): Last date of occupancy; „ }- Y COM>If MaALIMUSTRIAL Type of establishment: Design flow(based on 310 CUR I5.203): jwd Basis of design flow(seats/persons/sgft,etc.): Grease trap present.(yes or no):_ x Industrial waste holding tank present(yes or no):_ W n-sni�y a discharged to'the Title 5 system(Yes of no):_ readings,if available: East date aft oaupnacyluse: OTHER(describe): GENERAL UODRMATION Pumping Records Source of info matron: Was system pumped as part of the urspectron(yes or ): If yes,volume pumped --gallons—How was Reason forte ' 'PPS determined? TYPE SYSTEM tank,distribution box,soil absorption system overflow cesspool privy Shared system(yes or no)(if yes,attach previous inspection records,if any) InnovativdAlternative technology. Attach a copy of the current operation and maintenance contract(to be . obtained from system owner) _Tight tan¢ Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if(mown)and source of information: 0%�,�4 L a Were scwage odors dctccW when arriving at the site(yes or no):/�/' a Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: /O /�%//G Ae'll �G �� p 60/ Owner. 15-a n Date of Inspection: Q BUILDING SEWER(locate on site plan) Depth below grade: 46 Materials of constr cation: iron PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting evidence of leakage;etc.): SEPTIC TANIG v _(locn site plan) Depth below grade: Material of co>uaruictiom —metal. fiber glass_polye ftleae other(explain) if tank is metal list age: Is age confirmed by a Certificate of certificate). �— Compliance(yes or no):_(attach a copy of Dimensions: g u Sludge depth:To2 Distance from top of sludge to bottom of outlet tee or baffle: oz 9 Smm thickness.�_ Distance from top of scum to top of outlet tee or bale: .7 Distance from bottom of scum to bottom outlet tee or bale: How were dimensions determined: o/e AQa Comments(on pumping recommendations,inlet and drdet tee or baffle condition,structural integrity,liquid levels as to outlet invert,gvid�e�e of leeks .etc•); ` Hot Qe , Li,s 41...7 e. f e O GREASE TRAP(a/=" te 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 Conunellts(on pumping recommendations,inlet and outlet tee or battle condition,structural as related to outlet invert,evidence of leakage,etc.): iW01y,liquid levels Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Oyylle�; R Nip Date of Inspection: / 0 TIGHT or HOLDING TANK; (tank must be ' Pumped at time of mspecaon)(locate on site plan) . Depth below grade: Material of construction concrete metal fiberglass_1oIYethYIene other(explain): Dimensions: Capacity: gallons Design Flow: day Alarm present(yes or no): Alarm level: Alarm in working order(yes or nor Date of last pmwf Comments(condition of alarm and float switches,etc.)• DISTRIBUTION BOX: ✓� must be present opened)(locate on site plan) Depth of liquid level above outlet invert: 7 o/•"ot Comments(note if box is level and distribution to outlets equal,any, evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER (locate on site plan)" Pumps in working order.(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): i, n page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Addmst Owner. h sC� Date of Inspection: p SOUL ABSORPTION SYSTEM(SAS): Qocate on site plan,excavation not required) If SAS not located explain why: Tyw leachingc>=ibeM mm*w- i � 1"c9rf lea �� ��( S ,number,length: l ° leadringfieldx mmber,dimensions i overflow cesspool,number: to x 3o x ,k innovative/alternative system T"dname of tecbnology: Comments(note condition of soil,signs of hydraulic failure,level o pon etc.). f ding,damp soil,condition of vegetation, CESSPOOLS:cesspool must be pumped as of part rnspoctronxlocate on site plain) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer Depth of sawn 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.): PRIW.-'1locate on site plan) Materials of oonsrnkctiion; Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure:,level ofponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continue Property Address+ (,fct owner.. F--?'-+K COK, Date of Inspection: p 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. L7 11 TO /7/.d9� . Page 11 of 11 OFFICIAL INSPECTION FORM' NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM ` PART C. " SYSTEM INFORMATION(contiaawo Property Address: Owner. Date of Inspection: SM EXArvt Slope Surface water Check cellar q x ��•/ Shallow wells Estimated depth to ground water eet ( C' Please indicate(deck)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 proper ty/observation hole within 150 feet of SAS) TelP _.�ekkad with local Board of Hwlth explain �4 s Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You mast desccribe haw jou cqaMished the high ground water elevation: fir• CvM,1� IN�t 4) S ' r �7 •.r IS Ct�Ov (•ry .11 1000, ro ,.t ly �%- �r19 '- (r �✓ No. � Q Fee /� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 0(pprication for Migw6ar *pgtem Con5truction Permit Application for a Permit to Construct( )Repair(�)Upgrade( )Abandon( ) El Complete System individual Components Location Address or Lot No. Owner's Name,Address an Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. / Designer's Name,Address and Tel.No. 7 7/JU? Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder Other Type of Building "JAr'e'No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow IY360 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil 349 X Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued this B d o Health. / Signed Date / �l Application Approved by Date Z l d Application Disapproved for the following reasons Permit No. Date Issued No. 7! Q h R_3 r: Fee —5--d r k HE COMMONWEALTH OF MASSACHUSETTS Entered in computer: : LI-111/ PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS ✓ 0(ppYication for 3Dtgogaf *p6tem Construction Permit r Application Repair for a Permit to Construct ) Upgrade Abandon pp ( p ( Y)Upg ( ) ( ) O Complete System C7'Tndividual Components Location Address or Lot No. /70 7 / ���/ Owner's Name,Address/annd Tel.No. Assessor's Map/Parcel / ! + " rq WAa���� Installer's Name,Address,and Tel.No. Designer's,lame,Address and Tel.No. l�o!�d lo��i^Corls� t 77i�939 Type of Building: i Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( � Other Type of Building of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow //a gallons per day. Calculated daily flow 3.3d gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank ��(� i1'/S�`//19 Type of S.A.S. t/ -/I%9-4i C�l,GZOG)�>`y til� Description of Soil Nature of Repairs or Alterations(Answer when applicable) 7-/2/e X_l e-,eeW r Date last inspected: ' Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue�this d ofl ealth. Signed Date Z- / Application Approved by Date / d Application Disapproved for the following reasons Permit No. Date Issued'` —— THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERPFrY, that th//p���On-site Se age Disposal System Constructed( )Repaired (t4Upgraded ( ) Abandoned( )by � V 40' at /L7 G S t/1/Q Q///! 5 has een constructe��ff r a cordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ZI Cl_ 0 /dated Installer Designer The issuance of this permit sh4llnot be construed as a guarantee that the syste ' .� unctinmas dl rgned '2lfd Date Inspector C . No. �————---------------------�7�'�/� Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS li000a[ 6pgte ��i 5truction Permit Permission is hereby granted to Construct(// )Repair( grade( )Abandon( ) System located at 7 D S and as described in the above Application for Disposal System Construction Permit. The applicant recognizes hislher duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date: �'/�/�� Approved by `` NOTICE: This Form hs To Be Used For the Repair • Se tic Systems.Only. P Of Failed CERTIFICATION OF SKETCH AND APPLICATION FOR A DLSPOSAL WORKS CONSTRUCTION_PERMIT(W MOUT DESIGNED PLANSI � �D!>P!'r';1• ,��?I'�7�LD�hereby certify. that the application for disposal works construction permit signed by me dated. Zf/`O/ concerning the property located.at V /l% meets all of the following criteria:. ;he.ailed system i5 tonne;ttea to a resideacal dwelling only Tner e at r no commercial or business uses asscc�.ated with the dwelling. i ne soil.is classined as CLASS _ SS I and 1h ==oiation mte is less than or equai :o minutes per inc:L /7-ner:are . wetlands _ c "^ no we lands within I00 tee:ar 11e proposed senac srste:n A ,here are no pr,'vate wells within.l:0 e=of he wo-cesed septic s✓se:n. �.aere is no increase in flow and/or change in':se t)r0oosed t here are no varances.:.equeaed or needed- The bottom'of the.proposed leaching facility will not be located less than maximum ad e e�` uwe fee:above the 7 groundwat_-able ration. (Adjust the groundwater table.using the?rimptor method when amlicablej. if:the S.AS.will be located with 250 fee, - oi ati`•vegetated we:lan�s, the bot tom or he Proposed 1 p leaching fac ility ctltry will not be located less than fourteen(14)i:e:above the ttsaudmum adjusted ,groundwater table elevation, Pleaw compiete the foilowing: : .4) Top of Ground Surface BIevation(using GIS information) B) G.W.Elevation +the MAX.&gh G.W. Adjustment:,�6 6 g•�7 D .r1 - ' ENCE BETWEEN A and B 1 1, 47 SIGNED : DATE: [Sketch Proposed Plan Of system on back]. b=M&kkr awt 1 L RJ � COMMONWI�ALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL:.AFI''AIRS. DEPA-RTMENT OF`ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INS PE FORM-NOT.T'O .VOLUNTARY.ASSESSMENTS SUBSURFACE SE WAGED SYSTEM FORM PART A r CERTIFICATION Property Address: U 01 Owner's Nam Owner's Addr IVA 0,-)(P7S' DEp'T.N E . f -10wHEWT AS• Date of Inspection. Q , 'Name of Inspector: lease print) Company.Name: B ... Mailing�Ad.dress: Q.. ,:� Telephone Number-' e CERTIFICATION STATEMENT the information have person inspected the sewage disposal system at this.addr�on w.as'performed based on my �Pd I certify.that I ha p y . below is.true,accurate and completefuncti of on time and maintenance of on site sewage disposal systems.I.ant a DEP training and experience in the prop stem:. approved system inspector pursuantto Section.15.340 oiTitle'5(310 CMR 15.Ooo). ,The system: Passes Conditionally Passes Authority Needs F rtlier Evaluation by the Local Approving b. 'F�'tls �` Date: tT1 Inspe.cto•r s.Sipatu • shall submits copy of this inspection report to the Approving Authority deBgnrd of Health Or flow of 10 000 The system inspector DEP)within 30 days of completing this inspection.If:the system is a.1.1 rt system s sent to the buyer;if applicable,and the approving d or realer,the inspector and the system owner shalGsubmii the report to the appropriate regional office of to gp g DEP..The original should be sent to the system owner and cop e authority. Notes and Comments ins pection ec tiott and under the conditions of use?at that e of different. ****This report only descrtbes conditions at:.the ttnt P time.This inspection does not address how the system will perform in the future under the same or conditions of use. Title 5 Inspection Form 6/1.5/20.00 page 1 Page 2 of 1] `f 0 FICIAL. INSPECTION FORM-NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION 1+O.RM PART A t CE.RTIFICATION (continued) Property Address: 9 Owner: . Date of speetion: J /.0 / Inspection Summary: Check A,Ii;CD or E%AL.WAYS complete alFof Section D A. System Passes: .I have not found any information which indicates teat any of the failure criteria described in 310 CMR 15.303 or in310 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`tarik failure is immmant. System'will pass inspection if the existung 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 of,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 Hof the Board of Health): broken pipe(s)are replaced obstruction-is removed ND explain: Page 3 of 11. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: .� : A Owner: Date of spection: aTF/z 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 enviroriinent. 1. System will pass unless Board of Health determines in accordance with 310.CMR 15.303(1)(b).that the system is not functioning in a manner which will protect public health,safety and the environment:, Cesspool or privy.is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any determines that the system is functioning in a manner that protects the.public health;.safety and environment: _ The.system has a septic tank.and soil absorption system(SAS)and the SAS is within 100 feet of a. surface water supply or tributary to a surface water supply: The system has a septic tank and SAS and the SAS is within a Zone l-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 aseptic 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 arid 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 1 I ` OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE'SEWAGE DISPOSAL SYSTEM'INSPECTION FORM PART A CERTIFICATION(continued) Property Address: JMo , .k-11113. 6a' l Owner: r- Date of , pection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following--or 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 _Z' Static1iquid 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.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR' 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: I-)A To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gPd. You.must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no - _ the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any questibn in Section Ethe 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 underSection 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 I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ; PART B CHECKLIST PropertyAddress: 1�70 Owner Date o spection: � �n/ 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? _ V-Have large.volumes of water been introduced to the system recently or as part of this inspection? V/1—_ Were as built plans ofthe system obtained and examined?(If they were not available note as N/A) V _ Was the facility or dwelling inspected for signs of sewage back up Was the site inspected for signs of break out? F 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? f_ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The site and location of the Soil Absorption'System(SAS)or]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)J 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM :.PART C SYSTEM-INFORMATION Property Address: b Owner: c� Date of. spection: �)LQQ j FLOW CONDITIONS RESIDENTIAL Number of bedrooms(.design): Number of bedrooms(actual): 3 DESIGN flow based on 310;CMR 15.203 for exam�pple: 110 gpd x#of bedrooms): Number of current residents-6healIt t- w u>ok&Z-~ Does residence have a garbage grinder(yes or no)�,-V" Is laundry on a separate sewage system (yes or no):_.:[if yes separate inspection required] Laundry system inspected(yes or no)//Ijs- Seasonal use:(yes or Water meter readings-'if available(last 2 years usage(gpd)): Sump pump(yes or no): t" Last date of occupancy:, i,Occo v ( w 4,69,6 t� U COMMERCIAL/INDUSTRIAL. ,/Z-- 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: s Was system pumped as part of the in pection(yes or no):,e�� If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TY_ P�E/OF SYSTEM eptic 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 ins ailed(if known)and source of information: a Were sewage odors detected when arriving at the site(yes or nA. 6 Page 7 of 11 OFFICIAL INSPECTION FORM NOT:FOR VOLUNTARY-, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART'C:. SYSTEIV>(.INFORMATION.(continued) Property Address: 170 ,_. ��, /Lfl�l Owner t il�Gt:. 44 Date of pection: BUILDING SEWER(locate on site plan) / Depth below grade: Materials of construction: cast-iron 40 PVC.— other(explain): , Distance from pr'►.vate water supply well or suction line: Comments(on condition ofivints,venting;evidence of.leakage'etc): SEPTIC TANI{:Yf� (locate on site plan) Depth below grade: Material of construction:`concrete_metal_fiberglass p olyethylene other(explain) If tank is metal list age:— .Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) r a. Dimensions: �•� K 1C Sludge-depth: (� Distance from top of sludge to bottom.of.outlet tee.or,baffle: �. Scum.thickness: Distance from top of scum to top of outlet tee:or baffle: Distance.from bottom.of scum to bottom of outlet tee or baffle: {� t How were dimensioris determined: liquid levels It • structural integrity, q Comments(on pumping recommeri ations, inlet and outlet tee or baffle condition, a- elated.to outlei invert,evidence of leakage,etc.)/:J, GREASE TRAPs� 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 l 1 ` OFFICIAL:INSPECTION FORM NOT FOR _YOLUNTARY'ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION VORM ,PART.0 . SYSTEM'INI�ORMATION'(c�ntinued) I n V Property Address: lzo ,fi',?��� �,p Gt1 Owner: LcJ�2¢ j�'L- Date ofridpectiow TIGHT or HOLDING TANK- ank must'be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal _fiberglass polyetliylene 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: Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of -Ig kale into,or out of box,et .): PUMP CHAMBER• 1:-(locate on site plan) Pumps in working order Oyes or no): Alarms in working order(yes or no): Comments(note condition of pump cliamber,condition of pumps and appurtenanees,,etc::): Q Page 9 of I 1 OFFICIAL INSYEC.TIO.N FORM-NOT FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property-Address: 0 /9 _A� Owner: Date ok ispection: 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: a overflow cesspool,number:_ innovative/alternative system Type/name of teclurology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, .. .etc. _ jc.L�!/ZGC� • CESSPOOL/ ' (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: Material's of construction: Indication of.groundwater inflow(yes or.ro): 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: Coininents(note condition of soil,.signs of hydraulic failure,level of ponding,condition of vegetation,etc.): { 9 Page 10 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE'SEWAGE DISPOSAL SYSTEMJNSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: X) ,• � ��` t�— Owner: e'Date of I section: _ 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 waterrsupply enters the building. ke� 0� �5 3C0 I Page I"of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORIYIATION(continued) Property Address: ,Z' Owner r Date of 1 spection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated.depth to ground water / feet Please indicate(check).all methods used to deterniine 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 witli local Board of Health-explain: 'hecked with.local excavators, installers-(attach documentation) 1 _Accessed USGS database-explain: You must describe how you established the high ground water elevation: !• r n r 11 _T.O- ARN. . .. ... STABLE • : LOCATION' . . Al/" Z �;: ¢.y 7 SWA E .4 VILLAGE ASSESSOR'S:MAP &ZAT f �y0 1 INSTALLER'S NAME&P]TONE NO.f 7>' - 3 2,f` SEPTIC TANK CAPACITY: ODD .t` 5 asp i. LEACHING FACILITY: (type) "f 1 rn (size) 3�x NO.OF BEDROOMS 3 BUILDER OR OWNER PERMIT.DATE- ���d / COMPLIANCE DATE: Separation Distance Between the: L Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist . o, site or within 20Q feet of leaching facility. ) Feet Ede of Wetland and Leaching g Facility(Ifany.wetlands exist within 300 feet of leaching facility) Feet Furnished by ..__ .. t � , ��oF FT o Town of Barnstable inxivscnste Department of Health, Safety, and Environmental Services 9�A 16yg. ,off Public Health Division TED"ADS A P.O. Box 534, Hyannis MA 02601 I Office: 508-790-6265 Thomas A.McKean,RS,CHO FAX: .508-790-6304 Director of Public Health RECORD OF VERBAL COMMUNICATION _ i � : zc�,dam verbcomm.doc COMMONWEALTH OF 1VIASSACHUSETTS F•ENVIRONMENTAL.AFFAIRS. Vim" x EXECUTIVE OFFICE O /b DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5` OFFICIAL INSPECTION.FORM-NOT TOR VOLUNTARY AS ERSMSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM F PART A CERTIFICATION Property Address: .. V ,4' Owner's Nam ' Owner's Addr Date of Inspection. Ql Name of Inspector: Liep Company,Name:Mailing Address: U �Telephone Number: ` ��Cp CERTIFICATION STATEMENT 1 certify that I have personally inspected the sewage disposal system at this The insddress and ect on was pat the information erformed based on' my ried below is_true,'accurate and complete as of the time of the mspect�on p 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:. sses t` Conditionally Passes M 3 Needs F rther Evaluation by the Local Approving,Authority ils Date: Inspector's Signature. 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► . s ared ort to the a pem�opr ate regionr has a design al ow of officeoftl e0 gpd or greater,the inspector and the system owner,shall submit ther p 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 �4,` ****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 6/1-5/2000 page 1 �J Page 2 of 11 C OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS 6 G. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: /I Owner: . Date of spection: 0lJa1/0 / Inspection Summary: Check A,B;C;D or E 7 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: 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 b th e he Board PP Y 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 on lank 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 .ob structed p.i e's p ( )or due to a broken set tled 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 le' 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 ,n Page 3 of 11. OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE:,SEWAGE.DISPOSAL SYSTEM"INSPtCTION FORM PART A CERTIFICATION(continued) Property Address: l 42V. Owner: '. Date.of pection: 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 B..oard of.Health.determines in accordance with 310,CMR 15.303(1)(b)that the system is not functioning in a manner which will protect.pub lic'health,safety and the environment: Cesspool.or privy is within 50 feet of a surface water _ Cesspool or privy is withi''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 he..alth,safety.and environment: The system has a septic task and soil absorption.system(SAS)and the SAS is within 100 feet of a . surface_watersuppIy_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.**.t Meth od used toCdetermine distance **This system passes if•the well water analysisperformed at a DEP certified.laboratory; for coliform bacteria and volatile organic comp..oundsandicate's.that the well.is free from poiiution 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.. i r 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: j 126 'fi Owner: - TLC Date of pection: /9111C)/ A 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'/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 ofa cesspool or'privy`is within a Zone 1 ofa.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 U 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.] (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,therefor&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 facilitywith a design flow of 10,000 gpd4o 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no — _ the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply — _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any questibn 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: U Owner. WL Date o nspection: /;F/D /u= ; f 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 a. "ere,any,of the system components pumped out in the previous two.weeks.. Vol' ' I._ 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) 1 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 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 tepance of subsurface sewage disposal systems? ` 'The size and location of the Soil Absorption System.(SAS)on the site has been detertnmed based on: Yes 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 I 302(3)(b)] 5 Page 6 of 1 I OFFICIAL INSPECTION FORM-NOT FOR'VOLUNTARY ASSESSMENTS - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM -PART C SYSTEM INFORMATION o a r Property Address: , Owner: Date of. spection: FLOW CONDITIONS RESIDENTIAL Number ofbedrooms(design)::. 3. Number of bedrooms(actual):.. DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 73 Number of current residents: —� � ���'y�%l/lu';7 d �Sp 6&, C Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system (yes or no):,4,fW7f if yes separate inspection required] Laundry system inspected(yes or no):� Seasonal use: (yes or no): (g Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no): Last date of occupancy: '©o COMMERCIAL/IND USTRIAL Type of establishment: Design flow(based on 3I0 CMR 1.5.203): 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 t1w Qom' Pumping Records l9" Source of information: Q �p 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�F SYSTEM t,!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 urce of i format'on: / - Weresewage odors detected when arriving at the site(yes or no): 6 Page Tof 11 -t. OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART`C 'SYSTEM INFORMATION(continued) Property Address• 170— / � n y Owner: y ) Date of pection: BUILDING SEWER(locate on site plan) z Depth below grade: Materials of construction: xast iron ' 40 PVC,_other.(expIain); Distance from private water supply well or suction line: Comments(on condition of joints,venting,:evidence of leakage,etc.): SEPTIC TANK: f/ (locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene 's other(explain) _ If tank is metal list age:_ Is age confirmed by a Certificate,of Compliance(yes or no):—(attach a copy of certificate) r, Dimensions: !P-S Sludge depth: Distance from top of sludge to bottom.of.outlettee:or baffle d.. Scum,thickness: _ 0 ' utee or baffle:bistance from to ofcum totoP'of ogµ Distance'from bottom of•scum to bottom of outlet tee baffle: d� K How were dimensions determined: Commen ( pumping onrecommen ationtss, let and outlet'tee or baffle condition,structural integrity, liquid levels elated to outlet invert,evidence of leakage,etc.): s GREASE TRA/�P cate on site.plan) Depth below grade: ,_,. Material of construction:_concrete_metal_fiberglass polyethylene_other (explain): Dimensions: " Scum.thickness: Distance from top of scum to top of outlet.tee or baffle: Distance from bottom of scum to.bottom of outlet tee or baffle: Date of last pumping: -Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 `'OFFICIAL INSPECTION FORM—NOT FOR_VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C:. SYSTEM INFORMATION(continued) Property Address: Owner: P �- Date of pection: TIGHT or HOLDING TANK?�ank 'must be pumped at time of inspection)(locate on:site plan) Depth below grade: Material of construction: concrete metal . fberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or r.o): 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: cA4LC Q Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of kale into,or out of box, et .): , PUMP CHAMBERAO'—(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;): Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property.Address: J 7 MeC ' V Owner: Date o spection SOIL ABSORPTION SYSTEM (SAS): f locate on site"plan,excavation not required) If SAS not located explain why: • Type r . leaching pits,number: leaching chambers,number:: .leaching galleries,number: leaching trenches number,'lena the leaching fields,number,dimensions: sions: . overflow cesspool,number: k 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., n . &P ag9_ _ x. CESSPOOLS• cesspool must be pumped as part of inspection)(locate on site plan) V. Number and`configuration: _ Depih ,top of liquid to inlet invert: Depth of solids layer: Depth of scum.layer: Dimensions cesspool? ime sions of 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.): PRIVV-2fiocate on site plan) Materials of construction:. Dimensions: �.. Depth of solids: Cotments(note condition of soil,signs'of hydraulic failure, level of ponding,condition of vegetation,etc.): 9 i ' 1 Page 10 of 11 OFFICIAL INSPECTION<FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE,SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: V 1 Owner• _ ' Date of I pection: 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. o 110 R Page 1 l of 11 ; OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION(continued) a Property Address: fi�lzk�� a ' Owner: Date of, spection: 01 SITE EXAM Slope. s Surface water ' Check cellar Shallow wells f' Estimated depth to ground water feet Please indicate check)all methods used to determine the,high ground water elevation: Obtained from system design plans on record If checked,'date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with"local.Board of Health-explain: necked with,local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe'how'you established the high ground water elevation: 11 .