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HomeMy WebLinkAbout0038 NOBADEER ROAD - Health 38 Nobadeer Road Hyannis P A 250 136 it 0 Commonwealth of Massachusetts . C Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated 6/15/2000. Inspection forms may not be altered in any way. A. Certification 1. Property Information: 38 Nobadeer Rd. Property Address Richard Colace Owner's Name same Owner's Address Hyannis MA ,02601 City/Town State Zip Code r.,) Date of Inspection: 7/30/07 t Date c 2. Inspector: Matthew L. Childs ,j Name of Inspector same �* Company Name 4 Orchid Ln. rye Company Address W. Yarmouth . MA 02673 . City/Town State Zip Code 508-989-1479 Telephone Number « Certification Statement: I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection: The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 7/30/07 cS L Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will.perform in the future under the same or different conditions of use. Colace.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 16 y y Commonwealth of Massachusetts r Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form, A. Certification (cont.)' 38 Nobadeer Rd. Property Address Hyannis MA 02601 City/Town State Zip Code Richard Colace 7/30/07 Owner's Name Date of Inspection Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that ariy 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: passes , B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The-system,-upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in'the ❑ for the following statements. If"not determined," please explain.' , ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as + approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating.that the tank is less than 20.years old is available. ND Explain: N/A Colace.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 7M A. Certification (cont.) 38 Nobadeer Rd. Property Address Hyannis MA 02601 Cityrrown State Zip Code Richard Colace 7/30/07 Owner's Name Date of Inspection 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 ❑ obstruction is removed ❑ distribution box is leveled or replaced ND Explain: N/A ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: N/A 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 El.' Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh Colace.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M A. Certification (cont.) 38 Nobadeer Rd. Property Address Hyannis MA 02601 City/Town State Zip Code Richard Colace 7/30/07 Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health (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: N/A **This system passes if the well water analysis, performed at a DE certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: N/A Colace.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M A. Certification (cont.) 38 Nobadeer Rd. Property Address Hyannis MA 02601 City/Town State ZipCode Richard Colace 7/30/07 Owner's Name ' Date of Inspection D)System Failure Criteria Applicable to AII'Systems You must indicate "Yes" or"No"to each of the following for all inspections: Yes -No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ❑ ® 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. E ® 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. Colace.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 T Commonwealth of Massachusetts v Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M ' A. Certification (cont.) 38 Nobadeer Rd. Property Address Hyannis MA 02601 City/Town State Zip Code Richard Colace` _ 7/30/07 Owner's Name Date of Inspection E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section.D. YES NO ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water.supply ❑ ❑- the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well 0 + 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. R Colace.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6,of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ^M Subsurface Sewage Disposal System Form B. Checklist 38 Nobadeer Rd. Property Address Hyannis MA 1 02601 City/Town State Zip Code Richard Colace 7/30/07 Owner's Name Date of inspection Check if the following have been done. You must indicate"yes" or"no" as to each of the following: YES NO ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR.15.302(3)(b)] t Colace.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form o Not for Voluntary Assessments Subsurface Sewage Disposal System Form iv M C. System Information 38 Nobadeer Rd. Property Address Hyannis MA 02601 City/Town State Zip Code Richard Colace 7/30/07 Owner's Name Date of Inspection 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 gpd. Number of current residents: 2 Does residence have a garbage grinder? _ ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑.Yes ® No ,Laundry system inspected? ❑ Yes ® No N Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usa e d N/A ( Y 9 (gp ))� Sump pump? ❑ Yes Z No current . Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: N/A Design flow(based on 310 CMR 15.203): N/A - Gallons per day(gpd) Basis of design flow(seats/persons/sq:ft., etc.): N/A 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: N/A Last date of occupancy/use: N/A Date Other(describe): N/A Colace.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form a Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information (cont.) 38 Nobadeer Rd. Property Address Hyannis MA 02601 City/Town State Zip Code Richard Colace 7/30/07 Owner's Name Date of Inspection General Information Pumping Records: Source of information: owner Was system pumped as part of the inspection? ❑ Yes ® No N/A If yes, volume pumped: gallons How was quantity pumped determined? N/A Reason for pumping: N/A .Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ` ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any), ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed(if known) and source of information: N/A Were sewage odors detected when arriving at the site? ❑ Yes ® No Colace.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form aX Not for Voluntary Assessments Subsurface Sewage Disposal System Form ^M C. System Information (cont.) 38 Nobadeer Rd. Property Address Hyannis MA 02601 City/Town State Zip Code Richard Colace 7/30/07 Owner's Name Date of Inspection Building Sewer(locate on site plan): Depth below grade: 1.5'feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): All in good working order at time of inspection. Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of ❑ Yes ❑ No certificate) Dimensions: 8'x5'x5' outside 1000 gal Sludge depth: 2 Distance from top of sludge to bottom of outlet tee or baffle 3.5' Scum thickness .2' Distance from top of scum to top of outlet tee or baffle 4' Distance from bottom of scum to bottom of outlet tee or baffle .91 How were dimensions determined? sludge judge Colace.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments , M Subsurface Sewage Disposal System Form C. System Information cont. 38 Nobadeer Rd. Property Address ' Hyannis MA 02601 City/Town State Zip Code Richard Colace 7/30/07 Owner's Name Date of Inspection Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Tank shows no signs of leakage and appears to have been maintained regularly at time of inspection. Grease Trap (locate on site plan): Depth below grade: N/A feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): N/A 'Dimensions: , N/A Scum thickness _N/A Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle N/A Date of last pumping: N/A 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.): N/A Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/A Material of construction: ❑ concrete •❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): N/A Colace.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ; Subsurface Sewage Disposal System Form C. System Information (cont.) 38 Nobadeer Rd. Property Address Hyannis MA 02601 City/Town State Zip Code 4, Richard Colace ,7/30/07 Owner's Name Date of Inspection Tight or Holding Tank(cont.) N/A Dimensions: Capacity: N/A- gallons a ' Design Flow: _N/A gallons per day , Alarm present: ❑ Yes ❑ No - Alarm level: N/A Alarm in working order: ElYes❑ No Date of last pumping: N/A Date Comments (condition of alarm and float switches, etc.): N/A t Distribution Box (if present must be opened) (locate on site plan): y "Depth;of liquid level above outlet invert 0.01 . Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box is level with no solids carryover or leakage at time of inspection. Pump Chamber(locate on site plan): Pumps in working order: ,,• ❑ Yes ❑ No Alarms in working order: x ❑ Yes ❑ No • Colace.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ;M Subsurface Sewage Disposal System Form C. System Information (cont.) 38 Nobadeer Rd. Property Address Hyannis MA 02601 City/Town State Zip Code Richard Colace 7/30/07 Owner's Name Date of Inspection Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): N/A Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: ' Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 1 6'x6' precast pit with 3' of stone had a 2' level of ponding and no higher stain lines. SAS shows no signs of hydraulic failure. Colace.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 . X Commonwealth of Massachusetts * { Title 5 Official Inspection Form' Not for Voluntary Assessments i. Subsurface Sewage Disposal.System Form 'GSM � a C. System Information (cont.) 38 Nobadeer Rd. Property Address Hyannis MA 02601 CityFrown -_ State Zip Code Richard Colace 7/30/07 Owner's Name Date of Inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration. ^,, N/A . Depth.—top of liquid to inlet invert N/A N/A Depth of solids layer fi m . ., `N/A Depth of scum layer%. Dimensions of cesspool N/A „M N/A Materials of construction :` • , Indication of groundwater inflow = ❑ Yes ❑ `No a 4. Comments (note-condition of.soil; signs of hydraulic failure, level of ponding, condition_of vegetation, etc.): s` N/A r Privy(locate on site plan): Materials of construction: Dimensions , Depth of solids N/A Comments (note condition of soil, signs of hydraulic failure,-,level-of ponding, condition of vegetation, etc): ,. N/A "A k M i Colace.doc•11/2004 Title 5.Official inspection Form:Subsurface Sewage Disposal System Page 14 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 38 Nobadeer Rd. Property Address Hyannis MA 02601 City/Town State Zip Code Richard Colace 7/30/07 Owner's Name Date of Inspection 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. ® a eer Rd. /S #38 A 1-43' B-1-14' A 2-45' B-2-19' A 3-53' B-3-23' A-4-59' B-4-34' 0 �. bmd auger Colace.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 15 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information (cont.) 38 Nobadeer Rd. Property Address Hyannis MA 02601 City/Town State Zip Code Richard Colace 7/30/07 Owner's Name Date of Inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water: Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Hand auger 13' below elevation of bottom of SAS and did not encounter groundwater. System has adequate groundwater seperation. Colace.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 Town of Barnstable Op 1HE Tp� Regulatory Services •ARNSfASLE ; Thomas F. Geiler, Director MASS. 9$ 039. �• Public Health Division ArED��p Thomas McKean,Director 200 Main Street, Hyannis;MA 02601 Office: 508-862-4644 Fax: 508-790-004 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the "Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. d COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT.OF ENVIRONMENTAL PROTECT-LON,__ .. ... RECEIVED APR 15 2003 TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION / 2 Property Address: � OG���v ,QCJ MAP SO .,N /,r / ��� PARCEL • 1'6 to Owner's Name: l/ i " LvI Ghc.,,F LOT 2 Owner's Address: 11 GYM/ p c/y Date of Inspection: // Name of Inspector: ( lease print) Company Name: �i1/r/i ' Cy Mailing Address: o Telephone Number. Sow) c CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CivIR 15.000). The system: - Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: The system inspector shall submit a copy,of this+inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of ase Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 3, O, ro / Owner: Q Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sy m Passes:, I have not found any information which indicates that any of the failure criteria described in 310 CNfR 15.303 or in 310 CNIR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B�70ne tem Conditionally Passes: 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 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 inuninent. Systcm«ill 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 insecti pon if it is structurally sound. not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system «ill pass inspection if(-.kith approval of the Board of Health):: broken.pipe(s)are replaced obstruction is removed ND explain: Page 3 of 1 l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIIFICATION(continued) Property Address: Ike- Cl^76f�� Owner: �97e V?Q Date of Inspection: 4714 // C.�`F�rther Evaluation is Required by the Board of Health: �" Conditions evst which require fur ther rther evaluation by the Board of Health in order to determine if the s}-stem is failing to protect public health safety or the environment. I. System will pass unless Board of Health determines in accordance with 310 CNIR 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 wil.11ail 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 aseptic tank and SAS and the SAS is within a Zone 1 of a public water supple. The System has a septic tank and SAS and the SAS is«ithin 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply,well**. Method used to determine distance **This system passes if the well water analysis,performed_at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other. _ Page 4 of I l , OFFICIAL INSPECTION FOR_ M—NOT FOR VOLUNTARY ASSESSINIENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: o/ Owner: c, Date of Inspection: 3 . D. System Failure Criteria applicable to all systems: You must indicate"yes'or"no" to each of the following for all inspections: Yes N� _ V Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged gg SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or /cesspool ✓. -iquid depth in cesspool is less than 6"below invert or available volume is less than�/2 day flow t Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number /of times pumped lAny 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%titter supply or tributary to a surface water supply. (//Z Any portion of a cesspool or privy is within a Zone 1 of a public well. yy 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, performe•' DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates u;... me 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 arc 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 determinc what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must sertie a facility gpd- wits a design flow of I0,000 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 the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a'surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes" to'any question in;Section E.the system is considered a significant threat-or answered "yes" in Section D above the lar;;e system has failed.The owner or operator of any large system considered a significant threat under Section E or failedunder Section D shall upgrade the system in accordance with 310 CNM 15.304.The system owner should contact the appropriate regional office of the Department. Page S of 11 e� f OFFICIAL INSPECTION,FORNt='NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM-INSPECTION FORM PART B —`°CHECKLIST Property Address:' U Owner: Nei x. Date of Ins pcction: / - Check if the following have been done. You must indicate"yes"or"no"as to each of the following: YI/ No fi mping information was provided by the owner,occupant,or.Board of Health Were anv of the system componentso um t _ eyp ped out in the previous two weeks Has the sv_ stem re ceived n— otmal flows Fin[the r eviou .si<vow p week period _ Have large volumes'ofwater been introduced to the system recently or as part of this inspection =Were as built plans of the system obtained and examined?(lf,they.were not available note as N/A) "Was the facility or dwelling inspected for signs of se' back upA " Was the site inspected for signs of break out ` `Were all system components,excluding the SAS, located on site Fi _ Were the septic tank manholes'tincovered opened,and the interior of the tank inspected for the condition3 �7'�Ias es or tees,"material of construction, dimensions,depth of liquid,depth of sludge and depth of scum 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: w Y�no . xisting 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 CIAR 15.302(3)(b)1 b &. _ a Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: w e P14 ' Date of Inspection: --T� FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual):3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: © - Does residence have a garbage grinder(yes or no):/Y4 Is laundry on a separate sewage system(yes or no):AOV [if yes separate inspection required] Laundry system inspected(yes or no):A'O Seasonal use: (yes or no): cPs Water meter readings,if available(last 2 years,usage(gpd)): Sump Pump(yes or no): Last date of occupancy: CO NIMERCIAL/IND USTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/s4etc.): 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: OTN.ER be): GENERAL INFORMATION Pumping Records ' Source of information: /U vti C /- - —� S1� - 0 (1114 e t/ Was system pumped as part of the inspection(yes or no):_ If yes,volume pumped:__gallons-.How was quantity pumped determined'? Reason for pumping: T OF SYSTEM _Septic tank,distribution box, soil absorption system ' _Single cesspool Overflow cesspool —Pricy Shared system es or no if yes, attach previous— (y )(� y p inspect-ion 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): , Approxirnate age of all components, date insta ed(if known)and source of information: Were sewage odors detected when arriving at'he site(yes or no):_P-0 Page 7 of I l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: SAS�2 "P-0�"- CG?V- Ad " 14. Owner: , Date of Inspection BUILDING SEWER(locate on site plan) Depth below grade: Materials of constriction: cast iron &416 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:,_(locate on site plan) e Depth below grade: ILI Material of construction: oncrete_metal'_fiberglass___polyethylene _other(explain) If tank is metal list age- Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: �C Sludge depth: 'T Distance from top of sludge to bottom of outlet_ tee or baffle: 02 7n Scum thickness: Zl- /� Distance from top of scum to top of outlet tee or baffle: 1 Distance from bottom of scum to bot pf outlet tee r baffle- `� How were dimensions determined: 0 e A� ce Comments(on pumping recommendations, inlet and o et tee or baffle condition structural integrity, liquid levels as laced to outlet invert, •dense of 1 g , etc.):. / /� / / w! r.✓J .70 P,e-�� � G ti� G'y� BSc.��/�S /h O o L`/ • ►, � �� e�, Oro - ° /o c✓ GREASE TRAP:(/(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.): Page 8 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Property Address: /j/O 4C` Owner: Date of Inspection TIGHT or HOLDING TANK:�tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/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.): DISTRIBL i v J Dn%r r/...�( present must be'o ened)(1 ovate on site plan) Depth of liquid level abo%_ invert:��KJ✓N�►�, / Comments (note if box is lc•.cl arA distribution to outlets equal;`any evidence of solids carryover,any evidence of l e into or out of box,e4c.): /VO 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.): 4 Page 9of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 3 a.,:.41e-v -/�C, Owner: & e Date of Inspection: SOIL.ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: rleaching pits,number: leaching chambers,number: —� leaching galleries,number: ` leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool, number: innovativelaltemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation etc.): O d i q L C j Tq v, ,pY j Q / i.- o CESSPOOLS:AL-(cesspool must be pumped as part of inspection)(locate on site plan) .. Number and configuration: Depth-top of liquid to inlet invert: Depot ot•solids layer. Depth of scum layer: , Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hvdraulic failure, level of ponding,condition of vegetation-etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: "Depth of solids: Comments(not6 condition of soil, signs of hydraulic failure, level of ponding,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 (continued) Property Address: Obo.c'ee, R� Owner: Date of Inspe,-tion: 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. 1 pti-- S-ae_ 5�r o ww J � O ///j ->r3 ' k At Page I l of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner. f12tz-, Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water j3 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: - Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: �Ald 'IV— Oo4e -d You must describe how you established the hi h ground water elevation: f 6oA k" ®� A k / &1/OI v �G q, S._�•S ro =I — ooIc «` ���-�'"1 ci/Ar1 n.Ji.✓o.'�e-� . �i - � wd 7 �Q� `1 G- — � u n� 0�r ci��e✓ 33 o ov5c- ` L O CATION 3� S E��WffA G E PERMIT NO. VILLAGE 'A _ iI bf - INSTA LLER'S N A N E ADDRESS GUILDER OR OW R \ DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED 1?e5 _ � O� � p �� �� �� �/� � � THE COMMONWEALTH OF MASSACHUSETnS i BOA RDD F H SALT . 1..!..... OF.... Appliration for Diipuaal Works Tomitrurtion ramit Application is hereby made for a Permit to Construct �r Repair ( ) an Individual Sewage,Disposal 3ssystevi at ,/' 00 to dress .• or LoHo ;�� ner �.� Address a ---- ,�-. Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) a Other fixtures ............................................ w Design Flow.............. ______ __________________gallons per person per day. Total daily flow------------ ............gallons. WSeptic Tank—Liquid capacityl��4allons Length. Width................ Diameter................ Depth................ Disposal Trench—No_____________________ Width___...__.It/____._ Total Length.................... Total leaching area....................sq. ft. Seepage Pit No......../_........... Diameter.JP-__ _._. Depth below inlet____________________ Total leaching ft. Z Other Distribution box ( ) Dosing to ( ) L '—' Percolation Test Results Performe( Date_____________ a _m inch Depth of Test Pit... ,..� . Test Pit No. 1__�.-(� inutes per p Depth to ground water..__,100'1&_1, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Q+' ---•------------------------------------------------------------------------------•------------------•--------•---._......._---------•----------------------- 0 Description of Soil------------•--•---------------------•--------•-------------•-----------------••-------------------------------------------------------------------------------------••- x v w UNature of Repairs or Alterations—Answer when applicable...................................................._........................................... --------------------------------------------------------------------------------•--_._..............---•----...---------------------------.-.------------•----------•----..._••-•-•-•-•-............___. Agreement: The ttndersigned agrees to install the aforedescribed Indiv' ual Sewage Disposal System in accordance with the provisions of iITLL 5 of the State Sanitary Code- Tigned further agrees not to place the system in operation until a Certificate of Compliance has beAje of health. Signed 9 % ..,�..�...._ --•------------ ate ApplicationApproved By.................................................................................................. Application Disapproved for the following reasons_________________________________________________________________________________________________________________ ........................... -----------•-•-••---•-----------------.....-•••-••-_•-•_.. +_ Date t �- Issued__ Date �� . No......................... • FEB.............................. s THE COMMONWEALTH OF MASSACHUSETTS r BOARD,.OF HEALZh .�.1.. 1...........OF..... !y 1.�.... ................... ,Appliration for Disposal Works C onstrurtinat thrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal .... ff _ ............................................. io ..Address ,gyp Y or I of o. ----------------------- 0 O ner p Address , ( e I f Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder V-0 aOther—Type of Building ............................ No. of persons............................. Showers ( ) — Cafeteria ( ) Otherfixtures ........................................................... ••---......--------------------•----•--•••••------------.......--••------•--•-•------••. Design Flow........................ _ _ gallons per person ger day. Total daily flow__._....._..._..t.... .CD........... lons. WW ..._ ..-X al Septic Tank—Liquid"capacity-!�U Ions Length �.._P. Width................ Diameter---------------- Depth................ x Disposal Trench—No. .................... Width...-y............. Total Length.................... Total leaching area....................sq. ft. Jr Seepage Pit No--------/.----------- Diameter..//%_a.... Depth below inlet.................... Total leaching area>... ft. Z Other Distribution box ( ) Dosing tan �I � � a Percolation Test Results Performed by..._�---�.�---.•--------------------•--•-_-�-------••-------_-- Date..........................--------__-- Test Pit No. L.A_- :-:.minutes per inch Depth of Test Pit___�..: __.____.. Depth to ground water..__/, fs, Test Pit No. 2.......:........minutes per inch Depth of Test Pit.................... Depth to ground water........................ a --------------------------------------- •-••--............................................................................................................ 0 Description of Soil..............................................................................................................................................11....................... x --------------------------------------------------------------------------------------------------------------------------------------•-------------•---------•----•------•---•---•-----................ U Nature of Repairs or Alterations—Answer when applicable.____........................................................................................... ..-------•-------------•-----------------•-------------------------------------•--------•- Agreement: The undersigned agrees to install the aforedescribed Indiv ual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The wwavlsigned further agrees not to place the system in operation until a Certificate of Compliance has beeny. e rd of health. Signed------.f_._• ---- .. '`.._ti.....� 'Date ApplicationApproved BY.................................................................................................. ....................................... Date Application Disapproved for the following reasons:................................................................................................................ ......................................................................................................................................................................................................... Date PermitNo.......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS 1 BOARD OF; HEALTH � O F......... r•.► z ... .. .-�'.......................... (Intifiratr of TompliFaaur THIS IS TO CERTIFY, t the Indiv'du 1 S wage" Disposal System constructed.( ) or Repaired ( ) by....... . ..g.�s ----- -- -.... -----------------------•••--•••... has been installed in accordance with the provisions of TIT F 5 T'hf State Sanitary Coda des `ibed in the application for Disposal Works Construction Permit No.__.... `a ....._........ dated_--..__.-_ %f .............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �® .......OF........ ................... ��-............................... �. N0.... r FEE..... Disposal Works Tonstrttrtion runtit Permission is hereby granted_______________________ ____ ................. to Construe ! ) or Repit fan Individual SS ge s , Street G G q as shown on the ppli tion for Disposal Works Construction Permit N .�_Q -.9� -4-D•ated.__*---------------- ............................ :"...^tie '� " ----- p th DATE--- ( ---- B'W He FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS AsBuilt Page 1 of 2 0v5- LOCATION SEWAGE PERMIT M0. Q �Q I ILLAGE .�, y INSTALLER'S NAME ADDRESS e UILDER Olt OW R \DATE PERMIT ISSUED DATE COMPLIANCE ISSUED g'3 0 http://issgl2/intranet/propdata/prebuilt.aspx?mappar=250136&seq=1 1/20/2017