HomeMy WebLinkAbout0034 NIGHTINGALE LANE - Health 34 NIGHTINGALE'VANE;HYANNIS f
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Commonwealth of Massachusettsr
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
34 Nightingale Lane
Property Address
Charlie Howard
Owner Owner's Name
information is required for Hyannis Ma. 02601 2/16/2011
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
W
forms on the
computer,use 1. Inspector:
only the tab key
to move your Robert Paolini
cursor-do not Name of Inspector
use the return
key. Capewide Enterprises,LLC.
Company Name
P.O.Box 763
Company Address
Centerville Ma. 02632
�74 City/Town State Zip Code
(508)477-8877 S14454
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of.on situ
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of k;
Title 5 (310 CM 15.000). The system:
X Aw
win V lf
® Passes ❑ Conditionally Passes ❑ Fails —1
00
❑ Needs Further Evaluation by the Local Approving Authority
1 2/16/2011
Ins ctor's gnature 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. f
ell of t5ins 11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
° 34 Nightingale Lane
Property Address
Charlie Howard
Owner Owner's Name
information is required for Hyannis Ma. 02601 2/16/2011
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:
The septic system is in proper working order at the present time.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if aCertificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 34 Nightingale Lane
Property Address
Charlie Howard
Owner Owner's Name
information is required for Hyannis Ma. 02601 2/16/2011
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 ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if (with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain.below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
M 34 Nightingale Lane
Property Address
Charlie Howard
Owner Owner's Name
information is required for Hyannis Ma. 02601 2/16/2011
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
`*This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
x
SK;
St
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
El ® 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 1/z day flow
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
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Commonwealth of Massachusetts
w Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
34 Nightingale Lane
M
Property Address
Charlie Howard
k
t, owner Owner's Name
" information is H annis Ma. 02601 2/16/2011
1.1 required for Y
every page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
,a
. Yes No
Required pumping more than 4 times in the last year NOT due to clogged or
❑ ® obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or
❑ ® tributary to a surface water supply.
,a
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
s�
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
t, I
{
❑ ❑ 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
El Elthe system is located in a nitrogen sensitive area (Interim Wellhead Protection
ai Area—IWPA) or a mapped Zone II of a public water supply well
t[ If you have answered "yes"to any question in Section E the system is considered a significant threat,
q or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
It
F..
Commonwealth of Massachusetts
Title 5 Official Inspection Form
It Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
}
^M 34 Nightingale Lane
Property Address
Charlie Howard
Owner Owner's Name
information is Hyannis Ma. 02601 2/16/2011
£ required for y
every page. City/Town State Zip Code Date of Inspection
C. Checklist
k Check if the following have been done. You must indicate "yes"or"no"as to each of the following:
Yes No
El ® Pumping information was provided by the owner, occupant, or Board of Health
4
❑ ® 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
B ❑
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
st 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?
Xc
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
j inspected for the condition of the baffles or tees, material of construction,
i 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:
l 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
t>
6=
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
"w I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 34 Nightingale Lane
Property Address
Charlie Howard
Owner Owner's Name
information is required for Hyannis Ma. 02601 2/16/2011
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
r
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ® Yes ❑ No
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d NA
9 ( Y 9 (gp ))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: NA
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? - ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
34 Nightingale Lane
Property Address
` Charlie Howard
Owner Owner's Name
information is required for Hyannis Ma. 02601 2/16/2011.
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
z' Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
:i Source of information:
t
Was system pumped as part of the inspection? ❑ Yes ® No
f
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
❑ Septic tank, distribution box, soil absorption system
® Single cesspool
® Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
^M 34 Nightingale Lane
Property Address
Charlie Howard
Owner Owner's Name
information is required for Hyannis Ma. 02601 2/16/2011
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
t(
' Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
y" Depth below grade: 1
feet
Material of construction:
❑ cast iron ❑ 40 PVC Clay the
® other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.)
Joints appear tight.No evidence of Ieakage.System vented through the house vents.
f
Septic Tank(locate on site plan):
Depth below grade:
{ feet
Material of construction:
45
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
Y
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
# m Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
a
34 Nightingale Lane
Property Address
Charlie Howard
` Owner
Owner's Name
information is required for Hyannis Ma. 02601 2/16/2011
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
**4
Distance from top of scum to top of outlet tee or baffle
Fi
Distance from bottom of scum to bottom of outlet tee or baffle
L
�k
i
How were dimensions determined?
N
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
of
V
Grease Trap (locate on site plan):
Y
k Depth below grade: feet
�F
~
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
u�
= Dimensions:
Scum thickness
' Distance from top of scum to top of outlet tee or baffle
�y
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Fi
d
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
34 Nightingale Lane
Property Address
Charlie Howard
:. Owner Owner's Name
information is
required for Hyannis Ma. 02601 2/16/2011
every page. City/Town State Zip Code Date of Inspection
,10 D. System Information cont.
Y (cont.)
1+1
All Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
i
P{
;S
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):
f:±
a'
v
k4 Dimensions:
iN
Capacity:
x# gallons
r
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.):
a
Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
F'
t
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
a4 Commonwealth of Massachusetts
3. W Title 5 Official Inspection Form
'i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 34 Nightingale Lane
Property Address
Charlie Howard
Owner Owner's Name
information is required for Hyannis Ma. 02601 2/16/2011
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
' Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
>
evidence of leakage into or out of box, etc.):
t
.G�
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.):
t
:ry Soil Absorption System (SAS) (locate on site plan, excavation not required):
)
If SAS not located, explain why:
:F
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
:s
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 34 Nightingale Lane
xy�
Property Address
Charlie Howard
Owner Owner's Name
information is Hyannis Ma. 02601 2/16/2011
required for y
every page. City/Town State Zip Code Date of Inspection
{
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
Elleaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
s;.
vegetation, etc.):
4
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration Spilt system 2 and 2
Depth—top of liquid to inlet invert
a; Depth of solids layer
6" 3"
Oil 0„
Depth of scum layer
#, Dimensions of cesspool 3-6'x8' 1-2'x3'
Materials of construction Concrete block
r
a
Indication of groundwater inflow ❑ Yes ® No
s
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
,f
K
Commonwealth of Massachusetts
h.
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
ac°M 34 Nightingale Lane
Property Address
Charlie Howard
' Owner Owner's Name
information is required for Hyannis Ma. 02601 2/16/2011
h every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Sandy dry soil.No signs of hydraulic failure.Left system was dry.Overflow stain line was 32" below
invert.Right system main was up to outlet invert.Overflow was dry and stain line was 15" below invert.
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ta;
Privy(locate on site plan):
�r
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
II
x
yYy�y
fS
1
5`
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t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
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Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 34 Nightingale Lane
Property Address
Charlie Howard
Owner Owner's Name
information is required for Hyannis Ma. 02601 2/16/2011
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: Bottom of CP 37'
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:
As-Built
❑ Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database- explain:
You must describe how you established the high ground water elevation: .
USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 annual ranges of groundwater
elevations.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form r
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
c,M 34 Nightingale Lane
Property Address
Charlie Howard
Owner Owner's Name
information is Y
required for Hyannis Ma. 02601 2/16/2011
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
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Regulatory. Services Department
3 1
BARNSrABM
Public Health Division
200 Main Street,-Hyannis MA 02601. 2007
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL# 70083230000251782244 t
1/20/2011
Walter J. Glowacki
t
34 Nightingale Lane
Hyannis, MA 02601
ORDER-TO COMPLY WITH STATE�ENVIRONMENTAL CODE,TITLE 5
The septic system located at 34 Nightingale Lane,Hyannis MA was last inspected on
August 3, 2010 by.Brian K. Tilton", a certified septic inspector for the State of `
Massachusetts.
The inspection of the'septic system showed that the system"Conditionally Passed"
under the guidelines of 1995 TITLE 5 (310�CMR.15 00). .
. I
You are ordered to repair the-septic system within two (2).years from the date you
receive this notification by either(a) replacing the cesspool with a TITLE 5 compliant
system or(b)removing or properly abandoning the single cesspool and hiring a licensed
plumber to connect the'kitchen/laundrylo the existing two cesspool system.
Failure to repair the septic system within the deadline period will result in future
enforcement.action.- u.
PER ORDER OF»TH BOARD OF HEALTH -
dr.
s Mc ean, .S., CHO
Agent of the Board of Health n -`
e
y r
Commonwealth of Massachusetts _
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 34 Nightingale Lane
Property Address
Walter J. Glowacki
Owner Owner's Name
information is Hyannis MA 02601 8/03/2010
required for every H y y
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.
Important:When A. General Information
filling out forms
on the computer, (�
use only the tab 1. Inspector: �L/I
key to move your p
cursor-do not Brian K. Tilton
use the return Name of Inspector
key.
The Building Inspector of Cape Cod
Company Name
PO Box 307
Company Address
Eastham MA 02642
City/Town State Zip Code
508-255-9343 �S14392
Telephone Number License Number
1-0
B. Certification
I certify that I have personally inspected the sewage disposal system at this address andWiat tka
information reported below is true, accurate and complete as of the time of the inspection-The-lspection
was performed based on my training and experience in the proper function and maintenAn'ce cDn site
sewage disposal systems. I am a DEP approved system inspector pursuant to Secti%15 0 of
Title 5(310 CMR 15.000).The system: 3
f—► D
r ❑ Passes Z Conditionally Passes . ❑ Fails
W M
❑ Needs Further Evaluation by the Local Approving Authority
0
spe 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.
fib
34 Nightingale t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Dispo I System•Page 1 of 15
.L
Commonwealth of Massachusetts
W Title 5 Official Inspection- Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
34 Nightingale Lane _ e
a d
Property Address
Walter J. Glowacki
Owner Owner's Name
information is
required for every Hyannis MA 02601 8/03/2010
page. City/Town State 'Zip Code Date of Inspection
Bo Certification (cont.)
Inspection Summary: Check A,B,C,D or.E/a/ways complete all of Section D
A) System Passes:
❑ I have not foundany 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. ° '' "
G .L S
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 yea'rs old* or the septic tank(whether metal or not) is
structurally unsound, exhibits substantialJnfiltration 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: 4.
Single Cesspool under paved driveway for laundry and kitchen needs to be abandoned and plumbing
tied into existing two pool system. _r
❑ Observation'of sewage backup or break out or'higl static water level in the distribution box due'
'to broken or obstructed pipe(s)or.due to a broken, settled'oruneven distribution box. System will'
Ll
-°° pass inspection if(with approval of Board of Health).
-
t
{ broken pipe(s) are replaced
obstruction is removed _
z
34 Nightingale t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
s
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System form - Not for Voluntary Assessments
^M 34 Nightingale Lane
Property Address
Walter J. Glowacki
Owner Owner's Name
information is required for every Hyannis MA 02601 8/03/2010
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ 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:
Y
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 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
34 Nightingale t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form'- Not for Voluntary Assessments
GSM 34 Nightingale Lane
Property Address
Walter J. Glowacki
Owner Owner's Name
information is required for every Hyannis MA 02601 8/03/2010
page. City/Town State Zip Code Date of Inspection
Bo Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
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
El ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or.cesspool
Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
El ® 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.
0 ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
34 Nightingale t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
Commonwealth of Massachusetts
z Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 34 Nightingale Lane
Property Address
Walter J. Glowacki
Owner Owner's Name
information is required for every Hyannis MA 02601 8/03/2010
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® 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.
El ® 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
El ® the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone Il 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.
34 Nightingale t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection dorm
Subsurface Sewage Disposal System Form=.Not for Voluntary Assessments
�M 34 Nightingale_Lane
Property Address
Walter J. Glowacki
Owner Owner's Name
information is
required for every Hyannis MA 02601 8/03/2010
page. City/Town State r, Zip Code Date of Inspection
Co Checklist
Check if the following have been done..You.rmust indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information'was`provided by,the owner, occupant, or Board of Health
❑ ® Were any of the system,components pumped out in the previous two weeks?
® ❑ Has the system received,normal flows°.in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?. "
® ElWere 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?
Z ❑ Was the site inspected,for signs,of break out? n
® ❑ Were all system'components, excluding the`SAS, located on site?f
®' ❑ 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 pf'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
Z El
approximation of distance is unacceptable) [310 CMR 15.302(5)]
34 Nightingale t5insp•03/08 a Title b Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 '
I
Commonwealth of Massachusetts _
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 34 Nightingale Lane
Property Address
Walter J. Glowacki
Owner Owner's Name
information is required for every Hyannis MA 02601 8/03/2010
page. Cityfrown State Zip Code Date of Inspection
Do System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: Vacant
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ® Yes ❑ 'No
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears,usa e d '09= 43 GPD,
9 ( Y 9 (gpd)): '08= 197 GPD
Sump pump? ❑ Yes ® No
010
Last date of occupancy: 44/2/2
Commercial/Industrial Flow Conditions:
Type of Establishment: N/A
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system?„ ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: date
Other(describe):
34 Nightingale t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
Commonwealth of Massachusetts,
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
o wM 34 Nightingale Lane
Property Address
Walter J. Glowacki
Owner Owner's Name
information is required for every Hyannis MA 02601 8/03/2010
page. City/Town State Zip Code Date of Inspection
De System Information (cont.)
General Information
Pumping Records:
File
Source of information:
Was system pumped as part of the inspection? ❑ Yes ❑ No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
❑ Septic tank, distribution box, soil absorption system
® Single cesspool
® Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed(if known)and source of information:
1930's home was built.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
34 Nightingale t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 . Y'
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 34 Nightingale Lane
Property Address
Walter J. Glowacki
Owner
Owner's Name
information is required for every Hyannis MA 02601 8/03/2010
page. Cityrrown State Zip Code Date of Inspection
Do System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction: G
❑ cast iron ❑ 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
a ------------------------------------------------- ------------------------------------------------------------------------
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle.
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
34 Nightingale t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
° 34 Nightingale Lane
y
Property Address
Walter J. Glowacki
Owner Owner's Name
information is required for every Hyannis MA 02601 8/03/2010
page. Cityfrown State Zip Code Date of Inspection
Da 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.):
Grease Trap (locate on site plan):
_
Depth below grade: N/A
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.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: N/A
Material of construction:
❑ concrete ❑ metal ❑ fiberglass'" ❑polyethylene ❑ other(explain):
34 Nightingale l5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15
�!� Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°wM 34 Nightingale Lane
Property Address
Walter J. Glowacki
Owner Owner's Name
information is required for every Hyannis MA 02601 8/03/2010
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank (cont.)
Dimensions: N/A
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
Distribution Box (if present must be opened) (locate on site plan):
0„
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
No D box, single outlet overflow cesspool.
(Rump Chamber(locate on site plan):
Pumps in working order:. ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
34 Nightingale t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for.Voluntary Assessments
M 34 Nightingale Lane
Property Address
Walter J. Glowacki
Owner Owner's Name
information is required for every Hyannis MA 02601 8/03/2010
page. CitylTown State Zip Code Date of Inspection
D. System information (cont.) -
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:
Type:
leaching pits number:
y.
❑ leaching chambers number:
❑ leaching galleries number:
leaching trenches number, length: r
❑ leaching fields number, dimensions:
�I overflow cesspool number: (1) 5'x6'
❑ 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.):
Lawn over top, no evidence of back up or hydraulic failure, pit empty with staining to 4.5' system
functional.
34 Nightingale t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
0 Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 34 Nightingale Lane
Property Address
Walter J. Glowacki
Owner Owner's Name
information is required for every Hyannis MA 02601 8/03/2010
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration (3) 1 single and one with
overflow pool
Depth —top of liquid to inlet invert g'
Depth of solids layer
0,
Depth of scum layer
Dimensions of cesspool 6'Dx SW
Materials of construction Leach lock
Indication of groundwater inflow ❑ Yes ® No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Single pool required to be abandoned and plumbing tied into two pool system, asphalt driveway over
single pool and was not inspected. cesspool with overflow pool was found with 1" ponding, overflow
was dry, system is functional. No evidence of hydraulic failure.
(Privy (locate on site plan):
(Materials of construction:
N/A,
Dimensions
Depth of solids
Comments (note condition of soil,'signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
34 Nightingale t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 34 Nightingale Lane
Property Address
Walter J. Glowacki
Owner Owner's Name
information is required for every Hyannis MA 02601 8/03/2010
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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.
0 '
PATIO
1 0
SLO E
DWELLING
PAVED
DRI:VEWA`
N0 `TO'SCALE
A1=12" B1 1
A2= 7' B2= 22;5'
34 Nightingale l5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
o�M 34 Nightingale Lane
Property Address
Walter J. Glowacki
Owner Owner's Name
information is required for every �H annis MA 02601 8/03/2010
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope Y
Z Surface water
® Check cellar
Shallow wells
Estimated depth to high ground water. fe 1 e no water
et
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
z 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: f
You must describe how you established the high ground water elevation:
Hand augered test hole in bottom of overflow pool 6' below bottom, no water encountered.
34 Nightingale t5insp•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
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Cape Cod Commission: USGS Well Data- July 2010 Page 1 of 2
COO
United States Geological Survey
Observation Wells
Asa service to Cape officials,engineers and other interested parties,the Cape Cod Commission publishes
monthly groundwater data gathered by its Water Resources Office..'
The water level measurements shown below are taken monthly from United States Geological Survey
(USGS) observation wells and compiled during the last week of each month.They are published as soon as
possible thereafter.
Listed below are nine out of the 61 wells measured across Cape Cod by the Commission's Water Resources
Office. These nine are employed as index wells to be used With Technical Bulletin 92-001: Estimation of
HiA Groundwater Levels for Construction and Land use Planning to predict high groundwater levels..
For your convenience,we've also provided a link to USGS national data. See the last column in the table
and the footnote below.
To see what's happening in real time at a separate Well in Brewster„visit,the USGS site: USGS
41.4630070014901 MA-BMW 22 BREWSTER.MA. -
For further information about any of the data or links on this Ipage,please contact Hydrologist Gabrielle
Belfit at the Commission.offices(508-362-3828).
July 2010
USGS Site
Number"*
Water Record Record Departure from Average** links to USGS
Location Well N®. Level* High* Low* Monthly Overall
national water-
level database)
21.8
(provisional :
adjusted
Thanks to NOT NOT
Barnstable AIW Horsley 19.5 26.6 AVAILABLE AVAILABLE 41.395607016430.1
230 Witten Inc. AT THIS AT THIS
for assistance TIME TIME
in providing
substitute data
until
a new well
can be drilled.
Barnstable 24W 21.9 20.6 28.6 2.1 2.4 41415 40701650 01
2197] 20.6 2.4
Brewster BMW 21 8.3 6.9 13.6 1.4 1I 414518070020301
Chatham CGW 1�8 23.5 20.9 26.6 0.1 0.3 414100070011101
http://www.capecodcommission.org/wells.htm 8/11/2010
HIGH GROUND-WATER LEVEL COMPUTATION
A Date: Z3/Z
,ij
�*
Site Location: ` � ��� �"� Permit:
l7 � tafNCVI��
Owner: G710W C�f Phone: ;
Contractor: I 8y i 19 Ot_ Phone: 5 ZY-
V pR
Notes: q
STEP 1 Measure depth to water table f
to nearest 1/10 ft. i
(depth is in feet below land surface) Date:
m /dd/yy feet below Is
STEP 2 Using Water-Level Range Zone and Index Well ..
Map locate site and determine:
A) Appropriate index well PO4 W 2
B) Water-level range zone
STEP 3 Using monthly "Current Water Resources
Conditions" determine current depth to water
level for index well. ` 71: e
.mm/YY:
STEP 4 Using Table of Potential Water Level,Rise for--
index well (STEP 2A), current depth to water,
level for index well (STEP 3), and water-level
zone (STEP 26) determine water-level /1 `�
adjustment. - 0
STEPS x
Estimate depth to,high water by subtracting the
water-level adjustment (STEP 4) from � � 0
measured depth to water level at site (STEP 1).,
NOTE* Tables 1-9 "Potential INater-Level Rise" are attached as worksheets to this file.
monthly index well data: www.capecodcommission.org/wells.html
TROY WILLIAMS f.
SEPTIC INSPECTIONS Nod
Certified by MA Department of Environmental Protection OFg� (508) 7( '9-1819
40 Old Bass River Road
South Dennis,MA 02660
conxnormlem Of MaxsachusemOUR p
Executive Office of ErrAormentd Affairs
Department of
Environmental Protection
Wham F.Weld
rsayaaor -
may.xo
Davtd IlL Slruhs
Ca 4nW8iWvr
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
// CERTIFICATION
Property Address: /`� h , n �••�G' L ti. / u..1n'• S
y Address of Owner. e✓A, ,+
Date of Inspection: 1/ /I s'�y } (If different) �y
Name of Inspector: -7 t-j y o C (o�J111..,
Company Name,Address and Telephone Number:
CERTIFICATION STATEMENT ��✓n /t, < r 4- X1 0a c 7S
I certify that I have persohally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection..The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system: '
Passes
Conditionially Passes,
_ Needs Further Evaluation,-By the Local Approving Authority
_ ,Fails.
Inspector's Signature: Dater
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the repon to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B,C,or D: ,
A) SYSTEM PASSES.
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
,B) SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If'not determined', explain why rot)
The septic tank is metal,cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
(revl.ed //1S/9S) 1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
/ CERTIFICATION (continued) ,
Property Address:
Owner:
Date of Inspection:
� 95- ` '
B) SYSTEM CONDITIONALLY PASSES (continued)
_. Sewage backup or breakout or high static water level observed i•nrthe distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution.box. The system will pass inspection if(with approval of the
Board of Health):
broken pipe(s) are replaced
obstruction is removed
•'distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with'approval of the Board of Health]
broken pipe(s)are'replaced
Obstruction is removed
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require.further evaluation by„the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTK DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
4
Cesspool or privy is within 50 feet of a surface:water °
Cesspool or privy is within 50 feet of a bordering vegetated wetlandf or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT.PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT: ,
The system nas-a septic tani< ano soii aosorption system and is within 100 feet to a surface water supply or tributary tc a
surface'w ate`r supply';
The system has a sepijc tank and-soil absorption system and is within a Zone 1 of a public water supply well.
The system has aseptic tank and soil absorption system and is within 50 feet of a private water supply well.
The system llas a septic tank and"soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply.•weli, unless a well water`analysis,for coliform bacteria and volatile organic compounds indicates that the well is
free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
DI SYSTEM FAILS: a T
15
1 Have'determined tF at ther system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis $,
for this determination is Identified below.. The Board of Health.should be contacted to determine what will be necessary to correct"
k.the failure':. - k
Backup of,sewage into facility orsystem component due°to an 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:
evl"sect-.:B/15/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
// CERTIFICATION (continued)
Property Address: 4\ q i<
Owner:
N i q
Date of Inspection:
D] SYSTEM FAILS(continued):
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6' below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to dogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of.a public well.
Any portion of,a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety
and the environment because one or more of the following conditions exist: .
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
t
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 8/15/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: Al'
Owner: t_ ,
Date of Inspection:
Check'if the following have been done:
Pumping information was requested of the owner, occupant, and Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
As built plans have been obtained and examined. Note if they are not available with WA.
ZThe facility or dwelling was inspected for signs of sewage back-up.
✓ The system does not receive non-sanitary or industrial waste flow
ZThe site was inspected for'signs of breakout.
t/ All system components, excluding the Soil Absorption System, have been located on the site.
I✓��The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on existing information or
I/approximated by non-intrusive methods.
V The facility ow nP• lamed occupants, if different from.owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
s
r
(revised 8/15/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner: +, C-
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: gallons
Number of bedrooms: 3
Number of current residents: y
Garbage grinder (yes or no): N0
Laundry connected to system (yes or no):�
Seasonal use (yes or no): A/v
Water meter readings, if available:_ o w
Last date of occupancy:
COMMERCIAL/INDUSTRIAL: /✓/jp
Type of establishment:
Design flow: gallons/day
Grease trap present: (yes or no)_
industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)=
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION.
PUMPING /RECORDS and source of information: / /
V L) r'CA I �V C, ;•l A I C+ !J. — •-.—� s a2i 6/L j t c.T—OL.a..t}- 4/(�7 .
System pumped as part of inspection: (yes or no)� S
If yes, volume pumped !�'oU gallons
Reason for pumping: c c,v t. �w of �Jv` ✓ i '^S/�R—c ds u�,
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)
Other (explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information: Qr,
r"Vx_ SDrrS zi-
Sewage odors detected when arriving at the site: (yes or no)
,revised 8/15/95) S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
n / SYSTEM INFORMATION (continued)
Property Address: /" 1 24-;
Owner: /A/;G
Date of Inspection:
SEPTIC TANK:/All
•:E
(locate on site plan)
Depth below grade
Material of construction: _concrete _metal _FRP —other(explain)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage,-etc.)
GREASE TRAP:_/ 1 /
(locate on site plan) °
Depth below grade:
material of construction: _concrete _metal _FRP —other(explain)
Dimensions:
>cum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom ni «i,m I� bntlnm-0I ODU?! tee Or bdnlP
r. .
Comments:
recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
Integrity, evidence of leakage, etc-i
:revised 8/15/95) 6
rK
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner. II
Date of Inspection: y T. �-/-C.
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade:
Material of construction: _,concrete_metal_FRP—other(explain) .
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: A1/a
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
mote if level and distribution i; equal; e�idence of solids cam,over, evidence of leakage into or out of box, etc.)
PUMP CHAMBER:
(locate on site plan)
Pumps in working"order:(yes or no)
Comments:
mote condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 6/15/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: J /v; 77 - 5, �t .
Owner: JV:y 5
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not.determined to be present, explain:
Type:
leaching pits, number:_
leaching chambers, number:_
leaching galleries, number.
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number. Uk C. e,S S ")w s �.
Comments: (note condition of soil, signs of hyd aulic failure, level of.ponding, condition of vegetation,etc.)
A h Gr�JCt�
CESSPOOLS
(locate on site plan)
Number and configuration:_144 L t S <,���1 d(r w c ll�•- k• } L-� «, f G �` . �,.y
Depth-top of liquid to inlet invert:
Depth of solids layer.
Depth of scum layer: o /=
Dimensions of cesspool:
'materials of construction:. c/k.
indication of groundwater: c ,
inflow (cesspool must be,pumped as part of inspection) <2 s
Comments: (note condition-of soil, signs of hydraulic failure, level of pondin , condition of vegetation, etc.)
PRIVY: IL-119
(locate on site plan)
wA
Materials of construction: Dimensions:
Depth of solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 8/15/95) 8
SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (oontinuecl)
Property Address: '7 --IL2'1,
Owner.
Date of Inspection: /Y y
J—
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
O p✓�� , P
,20
a�
i
14"
�� +
DEPTH TO GROUNDWATER
Depth to groundwater: feet _ adjusted high groundwater level
method of determination or pprozimation: �� �.. c G� 5—�� o o
�. a v 7' ' �'( v
v • a� ,
revised 6/15/95) 9