HomeMy WebLinkAbout0623 OLD STRAWBERRY HILL ROAD - Health .r�
623 Old Strawberry`Hifi,koad
Hyannis
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
623 Old Strawberry Hill Rd.
Property Address
Diane Doherty
Owner Owners Name
information is required for every Hyannis Ma 02601 3/10/2010
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 forms A. General Information
on the computer,
use only the tab 1. Inspector ✓ I 0
key to move your
cursor-do not "t
Sean M. Jones
use the return
key. Name of Inspector F -va
CD
t
S.M.Jones Title V Septic Inspection '
�V Company Name { .
74 Beldan Ln.
Company Address41
Centerville Ma Q2632
Cityrrown State ip Code co
774-248-4850 SI 4522
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
E Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
3/10/2010
Inspectors 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.
t5ins•09108 Title 5 Official Inspection Forth:Subsurface 4
age Disposal System• ge 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
p 623 Old Strawberry Hill Rd.
Property Address
Diane Doherty
Owner Owner's Name
information is required for every Hyannis Ma 02601 3/10/2010
page. Citylrown 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:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available:
❑ Y ❑ N ❑ ND (Explain below):
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
X Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r 623 Old Strawberry Hill Rd.
Property Address
Diane Doherty
Owner Owner's Name
information is required for every Hyannis Ma 02601 3/10/2010
page. Cityrrown 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'< 623 Old Strawberry Hill Rd.
Property Address
Diane Doherty
Owner Owner's Name
information is required for every Hyannis Ma 02601 3/10/2010
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 coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool.
❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less
than %day flow
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
623 Old Strawberry Hill Rd.
Property Address
Diane Doherty
Owner Owner's Name
information is required for every Hyannis Ma 02601 3/10/2010
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 16,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes" to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�y 623 Old Strawberry Hill Rd.
Property Address
Diane Doherty
Owner Owner's Name
information is required for every Hyannis Ma 02601 3/10/2010
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected forthe condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption,System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 gpd
5
t5ins-09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
623 Old Strawberry Hill Rd.
Property Address
I
Diane Doherty
Owner Owner's Name
information is
required for every Hyannis Ma 02601 3/10/2010
page. CityrTown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
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
Seasonaluse? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
2008=54,000 total gallons=148 gpd 2009=71,250 total gallons=195 gpd
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
I
Water meter readings, if available:
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
623 Old Strawberry Hill Rd.
Property Address
Diane Doherty
Owner Owner's Name
information is required for every Hyannis Ma 02601 3/10/2010
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
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/Altemative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
623 Old Strawberry Hill Rd.
Property Address
Diane Doherty
Owner Owner's Name
information is required for every Hyannis Ma 02601 3/10/2010
page. Cityrrown state Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
original system installed 1983 per town records
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2.5
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.):
Joints ok, no leakage, vented through roof
Septic Tank(locate on site plan):
Depth below grade: 1.5
feet
Material of construction:
0 concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gallons
Sludge depth:
5"
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
623 Old Strawberry Hill Rd.
Property Address
Diane Doherty
Owner Owners Name
information is required for every Hyannis Ma 02601 3/10/2010
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
3'
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
10"
How were dimensions determined? Opened covers and took
measurements
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Water level in tank was at bottom of outlet invert. Inlet tee and outlet baffle intact. Tank was not
leaking and was structurally sound. Tank does not need to be cleaned now but should be done soon
and then again every 2 years as maintenance.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
623 Old Strawberry Hill Rd.
Property Address
Diane Doherty
Owner Owner's Name
information is required for every Hyannis Ma 02601 3/10/2010
page. Citylrown state Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
623 Old Strawberry Hill Rd.
Property Address
Diane Doherty
Owner Owner's Name
information is required for every Hyannis Ma 02601 3/10/2010
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0"
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Distribution box was functioning as intended.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order. D Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
623 Old Strawberry Hill Rd.
Property Address
Diane Doherty
Owner owner's Name
information is required for every Hyannis Ma 02601 3/10/2010
page. Cityrrown State Zip Code Date of Inspertion
D. System Information (cont.)
Type:
® leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number.
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/altemative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
At time of inspection the leach pit had 7"of available leaching and no signs of ever being higher.
Town of Barnstable regulations require 4.5"of available leaching for a 2 bedroom house. These
calculations are based upon a 6 foot wide pit with 2'of stone. See attached table dated 12/15/2009.
Cesspools(cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r 623 Old Strawberry Hill Rd.
Property Address
Diane Doherty
Owner owner's Name
4 information is Hyannis Ma 02601 3/10/2010
required for every y
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.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
ug
623 Old Strawberry Hill Rd.
Property Address
Diane Doherty
Owner Owner's Name
information is
required for every Hyannis Ma 02601 3/10/2010
page. CityfTown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
P 3
3
i
A-i
/ 0p
A-�
w�1x
3 � .
0- >'- 34)
t5ins•09108 Title 5 Official Inspection Foam Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
`+ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
623 Old Strawberry Hill Rd.
Property Address
Diane Doherty
Owner Owner's Name
information is
required for every Hyannis Ma 02601 3/10/2010
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. 70
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
1
You must describe how you established the high ground water elevation:
groundwater elevation was establishec by accessing Town of Barnstable groundwater contour map.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 116 of 17
Commonwealth of Massachusetts
`+ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y� 623 Old Strawberry Hill Rd.
Property Address
Diane Doherty
Owner Owner's Name
information is required for every Hyannis Ma 02601 3/10/2010
page. CityrFown 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
r
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
Town of Barnstable
Barnstable
Regulatory Services Department
r Public Health Division
BA ISM
►639 � 200 Main Street, Hyannis MA 02601
ADD MA'I a� s
2007
Orrice: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 "Tomas A.McKean,CHO
NOTICE TO ALL SEPTIC INSPECTORS
December 15, 2009
This notice is being mailed to address the interpretation of Chapter 360 - 9.1
[Added 2-19-2008]
Septic systems consisting of a leaching pit with a liquid depth of less than six inches
below the invert and/or with the available volume less than of one day's flow shall be
upgraded to conform to 310 CMR 15.00, the State Environmental Code, Title V,
Minimum Requirements for the Subsurface Disposal of Sanitary Sewage, and Town of
Barnstable Board of Health Regulations.
Table of Required. Distances Necessary to Meet 24 Hour Storage from
Invert to Liquid Level
These calculations are based upon a six-foot wide leach pit. Please confirm effective
width in the field (amount of stone).
2 BR's 3 BR's 4 BR's 5 BR's
(220 d) (330 d 440 d 550 d
6' dia. Cesspool
no stone (r=3') 1299 18" 25" 31"
6' dia. Pit w/ 1'
stone (r=4') 7" 10 1/2" 14"* 17 1/2"*
6' dia. Pit w/ 2'
stone (r=5') 4 1/2" 6 %2 " 9" 1119
6' dia. Pit w/ 3'
stone (r=69) 3" 4 3/4" 6 1/4" 7 3/4"
6' dia. Pit wl 4'
stone (r=7') 2 1/411 1 3 1/2" 4 1/211 5 1/2"
*Leach pit is out of.compliance due to not enough capacity.
If the distance from the inlet invert to the liquid level or historic stain line of the leaching
pit or cesspool is less than the required distance as shown in.the table, then the soil
absorption system is considered "failed" according to the local Board of Health septic
inspection, regulation.
Q:\SEPTIC\LET DEC2009 To Septic Inspectors chart-A.doc
ECOJECH IAAP 'ZJ3
Environmental PARCEL
www.eco-tech.us ._07
THIS FORM IS A FACSIMILE OF THE STANDARD SEPTIC INSPECTION FORM ISSUED BY THE MASSACHUSETTS DEPARTMENT
OF ENVIRONMENTAL PROTECTION(revised 6/15/2000)
TITLE 5
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 623 Old Strawberry Hill Road
Centerville
Owner's Name: Priscilla Severance
Owner's Address: P.O Box 1065
Centerville,MA 02632 1
Date of Inspection: April 17, 2004
! b
Name of Inspector: (Please Print) David D. Coughanowr,R.S. TlEa
Company Name: Eco-Tech Environmental
Mailing Address: 43 Triangle Circle N
Centerville,MA 02563
Telephone Number: (508)364-0894 0
CERTIFICATION STATEMENT:
ca
I certify that I have personally inspected the sewage disposal system at this address and that the inforr Lion reo ted r--
below is true,accurate and complete as of the time of the inspection.The inspection was performed b ed on m}`�� rn
training and experience in the proper function and maintenance of on-site sewage disposal systems. I a DEP
approved system inspector pursuant to section 15.340 of Title 5(310 CMR 15.000).The system:
X Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature �' C"'�"�`--- � 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
Inspector's Note—> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger
any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed
on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination.
****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.
Tide 5 Inspection Form 6/15/2000 page 1
Y
Page 2 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 623 Old Strawberry Hill Road
Centerville
Owner: Priscilla Severance
Date of Inspection: April 17, 2004
INSPECTION SUMMARY: Check A,B,C,D or E/ALWAYS complete all of section D:
A] System Passes:
Yes I have not found any information which indicates that any of the failure criteria described in 310 CNM
5.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
COMMENTS:
B] System Conditionally Passes:
One or more system components as described in the"Conditional Pass" section need to be replaced or
repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no,or not determined(Y,N,or ND). in the_for the following statements. If"not determined"please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not),is structurally
unsound,exhibits substantial infiltration or exfiltration,or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or breakout or high static water level in the 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 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 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
ND explain
2
Page 3 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 623 Old Strawberry Hill Road
Centerville
Owner: Priscilla Severance
Date of Inspection: April 17, 2004
C) Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety and 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.
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 by a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form
3) OTHER
3
Page 4 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 623 Old Strawberry Hill Road
Centerville
Owner: Priscilla Severance
Date of Inspection: April 17, 2004
D)System Failure Criteria applicable to all systems:
You must indicate either"yes" or"no"to each of the following for all inspections:
I have determined that one or more of the following failure conditions exist as described 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 the failure.
yes no
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool.
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool.
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool.
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow.
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
X Any portion of the SAS,cesspool or privy is below high groundwater elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well
X Any portion of a cesspool or privy is within 50 feet of a private water supply well
X 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 by a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form)
No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore,the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E)Large 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
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone II of a public water supply well.
If you have answered"yes" to any question in Section E the system is considered a significant threat,or answered
"yes" in section D above the large system has failed.The owner or operator of any large system considered a
significant threat under section E or failed under section D shall upgrade the system in accordance with 310 CUR
15.304.The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 623 Old Strawberry Hill Road
Centerville
Owner: Priscilla Severance
Date of Inspection: April 17, 2004
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
Y _ Pumping information was provided by the owner,occupant or Board of Health.
N Were any of the system components pumped out in the last two weeks?
Y _ Has the system received normal flows in the previous two week period?
N Have large volumes of water been introduced to the system recently or as part of this inspection?
Y _ Were as built plans of the system obtained and examined?(If they were not available as N/A)
Y _ Was the facility or dwelling inspected for signs of sewage back-up?
Y _ Was the site inspected for signs of breakout?
including
Y _ Were all system components,exeluding the SAS. located on site?
Y _ Were the septic tank manholes uncovered,opened,and the interior of the septic tank inspected for
the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of
scum.?
Y _ Was the facility owner(and occupants,if different from owner)provided with information on the proper
maintenance of subsurface disposal systems?
For information on the proper maintenance of subsurface disposal systems please go to:
WWW.ECO-TECH.US
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Y _ Existing information. For example,Plan at the Board of Health.
Y _ Determined in the field(if any of the failure criteria related to part C is at issue,approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)]
5
Page 6 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 623 Old Strawberry Hill Road
Centerville
Owner: Priscilla Severance
Date of Inspection: April 17,2004
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): n/a Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a—No plan on file at Health Dept.
Number of current residents 1
Does the residence have a garbage grinder(yes or no): no
Is laundry on a separate sewage system(yes or no): no :(If yes, separate inspection required)
Laundry system inspected (yes or no): n/a
Seasonal use(yes or no): no
Water meter readings,if available(last two year's usage(gpd): 68 gpd
Sump Pump(yes or no): no
Last date of occupancy: current
COMMERCIAL/INDUS TRL4 L:
Type of establishment:
Design flow(based on 310 CMR 15.203):: gpd
Basis of design flow(seats/persons/sgft/etc.):
Grease trap present: (yes or no)_
Industrial waste holding tank present: (yes or no):
Non-sanitary waste discharged to the Title 5 system: (yes or no).
Water meter readings,if available:
Last date of occupancy/use:_
OTHER: (Describe):
GENERAL INFORMATION
PUMPING RECORDS
Source of information: System last pumped in July 2003 (Owner)
Was system pumped as part of the inspection: (yes or no) No
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM:
X 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/Alternate 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:
Age: 22+years Certificate of Compliance issued 3/18/83 (BOH permit#82-785)
Were sewage odors detected when arriving at the site: (yes or no) no
6
Page 7 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 623 Old Strawberry Hill Road
Centerville
Owner: Priscilla Severance
Date of Inspection: April 17,2004
BUILDING SEWER_(Locate on site plan)
Depth below grade: 2 ft
Material of construction:_cast iron X 40 PVC_other(explain)
Distance from private water supply well or suction line 20+
Comments: (on condition of joints,venting,evidence of leakage,etc.)
Sewer is vented through roof and appears structurally sound with no evidence of leakage or backup into dwelling
SEPTIC TANK:Yes (locate on site plan)
Depth below grade: 24 inches
Material of construction: X concrete_metal_fiberglass_polyethylene
_other(explain)
If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(yes or no):_(attach a copy of
certificate)
Dimensions: 8.5 ft x 5 ft x 5 ft(1000 gallon)
Sludge depth: 5 in
Distance from top of sludge to bottom of outlet tee or baffle: 29 in
Scum thickness: trace
Distance from top of scum to top of outlet tee or baffle: 10 in
Distance from bottom of scum to bottom of outlet tee or baffle: 14 in
How dimensions were determined: Probe to top of tank
Comments: (on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
Pumping not required at this time but maintenance pumping is recommended eve!y 2 years. Liquid level at
outlet invert.Tank and tees appear structurally sound and functioning as intended.No evidence of leakage in or out.
GREASE TRAP: none (locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_fiberglass_polyethylene
other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:_
Date of last pumping:
Comments: (on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 623 Old Strawberry Hill Road
Centerville
Owner: Priscilla Severance
Date of Inspection: April 17, 2004
TIGHT OR HOLDING TANK: none (Tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal _fiberglass_polyethylene_other(explain)
Dimensions:
Capacity: gallons
Design flow:_gallons/day
Alarm present(yes or no):_
Alarm level:_ Alarm in working order(yes or no):_
Date of last pumping:
Comments:(condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX: Yes (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: at outlet invert
Comments:(note if box is level and distribution to outlets is equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.)
D-box appears structurally sound with no evidence of leakage in or out.Effluent level at outlet invert.
Few solids in tank.
PUMP CHAMBER: none (locate on site plan)
Pumps in working order: (yes or no)
Alarms in working order: (yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
I
8
Page 9 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 623 Old Strawberry Hill Road
P rh' m'
Centerville
Owner: Priscilla Severance
Date of Inspection: April 17, 2004
SOIL ABSORPTION SYSTEM(SAS): Yes (locate on site plan;excavation not required)
If SAS not located,explain why:
Type:
X leaching pits,number 1
_leaching chambers,number
_leaching galleries,number
_leaching trenches,number,length
_leaching fields,number,dimensions
_overflow cesspool,number
—innovative/alternate system Type/name of Technology
Comments: (note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.)
Soils above leaching pit appeared unsaturated.No evidence of surface ponding,breakout,lush vegetation,or
other evidence of hydraulic failure was observed. Leach pit contained 15 inches of effluent.
CESSPOOLS: none (cesspool must be pumped at time of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,
etc.):
PRIVY: none (locate on site plan)
Materials of construction:
Dimensions:_
Depth of solids:
Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
LOCATION SEWAGE PERMIT NO.
Lot 24 Old Strawberry Hill Rd. 82-785
VILLAGE —
Hyannis
INSTALLER'S NAME ► ADDRESS
Robert R_ O,Jr Co. T_pe_
Great Western Rd. North Harwich
R UI-LDER OR OWNER
James Maddalena
DATE PERMIT ISSUED 12 16 82
DATE COMPLIANCE ISSUED ��
,,,� �� i
� y.� ._._._----
�'
o ,+
� �
� _ ...� �,
o•
•�
;� .�
� �.
t-
Page 10 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 623 Old Strawberry Hill Road
Centerville
Owner: Priscilla Severance
Date of Inspection: April 17, 2004
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100'(Locate where public water supply enters the building)
LOCATIONS
A B
1 27 ft 20 ft
2 23 Ft 24 ft
3 20 ft 30 ft
4 21 ft 38 ft
EXISTING
DWELLING
# 623
A 6
w
D BOX 0 O Z
❑ 2I J
3
LE SEPTIC w
PIT
. TANK �
3
I
OLD STRAWBERRY HILL ROAD NOT TO SCALE
10
Page 11 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 623 Old Strawberry Hill Road
Centerville
Owner: Priscilla Severance
Date of Inspection: April 17,2004
SITE EXAM
Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to groundwater: 30+ feet
Please indicate(check)all methods used to determine 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 local excavators,installers-attach documentation)
X Accessed USGS database
You must describe how you established the high ground water elevation.
Barnstable GIS department records indicate that property is over 30 feet above groundwater table.
11