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HomeMy WebLinkAbout0015 PORTSIDE DRIVE - Health 15 Po Drive won Hyannis P i4 = 289 069 I �Ir 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �'nt Property Address Owner Owner's Name A '`_' information is � ! ,�n/�• y3� required for every /�// t• page. City/Town ®� State Zip Code Date of Ins ctioA h 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 A. General Information filling out forms on the computer, use only the tab key to move your Inspector: cursor not return / use the return key. Name of Inspector r� Company Name 14F61 A/ Company Address24:-Q L/ City/Town _ _ aZ State �f Zip Code I elephonemumoer O ! — ® " �-- License Number Bo 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. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: Passes ❑ Conditional) Passes s ❑ Fails ❑ Ne ds Further Evaluation by the Local Approving Authority 4a' Inspect is Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the -V� 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 1 of 17 t VS Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System/Form-Not for Voluntary Assessments Owner Owner ame Proper's ty Address tot C4 9 N information is — required for every 4o f is 0a&o, page. City/Town State -ZipCode Date of nsp tion Bo Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) ;Syste Passes: 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 2 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name _ information is , required for every A—4.f page. City/Town State Zip Code Date of ns ction Bo Certification (Cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if Pumps/alarms are repaired. 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. I. 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 I ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 C®M m®nwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owners Name A �� information 0 required for every page, City/Town Bo Certc cation (cont.) State Zip Code Date Ins ection f� 2. System will fail unless the Board of Health (and Public water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well'water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: I 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Tie 5 Official Inspection ec ° - Subsurface Sewage Disposal System Form -No'f®Voluntary Assessments Property Address / V /j4a. r Owner information is Owner's Name required for every g 61#1l s ®d 6 01 / d page. City/Town State O Zip Code Date Ins ection Es. Certification (cont.) Yes No ❑ Required pumping more than 4 times in the last year iVOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ny 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 ributary to a surface water supply. ❑ Any portion of a or cesspool privy is P p y within a Zone 1 of a public well. ❑ Lam/ 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. [Phis 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 nd chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- (0,000gpd. ❑ Ze The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ EJ 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.doc•rev.6116 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 15 A4 4SW4 Property Address Owner Owner's Name 11, information is required for every G� A4 tea 601 3 page. City/Town State ZipCode Date of nspection C. Checklist Check if the following have been done. You must indicate "yes"or"no"as to each of the following: Yes ❑ 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? I� ❑ H s 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 L#� 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? �l Were all system components, exclud ing ding 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. L�r o 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): — Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Yso t5ins.doc-rev.6/16 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '4 M s// Property Address pwrlr� _ 1— 5 Owner Owner's Name information is required for every ®1 0 page. City/Town State o�1® Zip Code Date of 111spettion U. bystem Information Description: // e IC 4o r " ,tom Number of current residents: Does residence have a garbage grinder? ❑ Yes []No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes No Laundry system inspected? ❑ Yes No Seasonal use? ❑ Yes No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes No Last date of occupancy: 6:,4�l�y Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc-rev.6/16 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 efor Voluntary Assessments �J rOcJQ I% Property Address Owner Owners Name information is / required for every q�rl/s /� s/c�6 C?/ 3 page. City/Town State Zip Code Date of InsPectiAn Do System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: /✓D A4�j ��►� G�I��/ Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Ty;7Septic tank distributton box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c� /s0 4—v 10^ r e�t4 Owner information isOwner's Name Property Addressrequired for every p0 page. City/Town State Zip Code Date of Idspeofion Do System Information (coat.) Approximate age of all components, date installe (if known)and source of information: �9��— �o// Were sewage odors detected when arriving at the site? ❑ Yes Flo Building Sewer(locate on site plan): Depth below grade: �J feet Material of constructi;4.-0- ❑ cast iron PVC ❑ other(explain): Distance from private water supply well or suction line: ` C feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: feet Matal on eristruction: concrete ❑ metal ❑ polyethylene fiberglass ❑ poi eth y y ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certific te) ❑ Yes ❑ No Dimensions: X 0� Sludge depth: / S 15ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts F W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i5 Property Address k-44Owner Owner's Name information is required for every y4 8I/i'1 Sf � page. City/Town State Zip Code Date)of In ection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle 2 Distance from bottom of scum to bottom of outlet tee or baffle / How were dimensions determined? I"v/e o� Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): �a&4 4, o#4 -1�S rH co o?C,/J 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.doc-rev.6116 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 Property Address Owner Owner's Name information is o required for every oil ®� I page. City/Town --- State Zip Code Date of I spe ion 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.doc•rev.6/16 ICI Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G M WSJ Propert�resAdd s 4: � � ------- ✓- Owner Owner's Name information is required for every g -4®/ ? r page. city own State —Zip Code .3 P Date of sp tion D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Bump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 P Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address k-4 CU Y Owner Owner's Name information is required for every y{✓f/ yo�6OI page. City/Town State Zip Code Date of nspe ion D. System Information (cont.) Type O�t ❑ leaching pits number: ❑ 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.): Geloci ® ' ' o4�,0 c��tte &V X 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 I Commonwealth of Massachusetts Title 5 Offici al Inspects®n Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments IS Property Address k-toR (�g� Owner Owner's Name /� information is �p required for every rl i lu /� 0;16®/ 3 ® O page. City/Town State Zip Code Date of nsp ction 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.doc•rev.6/16 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 1S `M i or-¢,sr4 Property Address S( A Owner Owner's Name information is ®/ required for every AiHN 0� h-6 page. City/Town State Zip Code Date of InspeCtion D. System Information (coot.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two ermanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate ;hand-sketch re p c water supply enters the building. Check one of the boxes below: in the area below ❑ drawing attached separately ` GG llo� SPA« 5'o�C 1,t3- 3.633. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ents Property Address r Owner i�9 Owner's Name o C information is � l a required for every /`7 c,C;0141 page. City/Town C;P�- 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: 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 oard of Health - "/ � explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You mu describe h0A you es/ablished the high round water elevatin: ,IV C4#1 /0-C ov,? 07'�" 570 /0 LI 15 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev:6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ®�Property Address �� r� Owner Owner's Name / information is !/ 1 required for every g P S �,j b o� page. City/Town State Zip Code Date Onspdrction E. Report Completeness Checklist Ins ection Summary:A, B, C, D, or E checked Ins ection p Summary D(System Failure Criteria Applicable to All Systems)completed Ind 5 em Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file r i t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 } �D !� t jq/PCommonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Jc- Property AddressCw /� T Z9 O .e✓ 07 Ll s r>er Ow pees Name infommtion is requted for every ✓1✓/f 1��l co oZ 6 61 page. City/Town C71State Zip Code Caste 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. Irn portang ou fo Men A- General Information ftrmg out forms on the computer, .use only the tab 1. Inspector: key to move your cursor-do not ✓�/ n /SQ Ili use the return Name of Inspector Company Address ,- A City/Town ce ^�/O Stet® _0�PA Zip Code Telephone er j 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. i am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CM 16.000). The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspectorf 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 god 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. Ons•Y13 The 50fndal Ire pectlon F om Subsuface Sewage0lspced System•Page 1 of 17 ' Commonwealth of Massachusetts Title 5 OfFigial Inspection Form Subsurface Sewage' Di4661 System F /e- Prop" orm •Not for Voluntary Assessments 4S/ t Address `jiG �✓ Innfforrmation is ON nee Nan , ool C 0 required for every NN I 11 !1�j�.r----.--- page. atyRown State Zip Oode Date OfAfISMW B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System P s: 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 des', "no"or"not determined"(Y,.N, ND) for the following statements. If"not determined,'please exVain. 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 efittration 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 wiU 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): One 143 Title 5 Official Ire pectanFcrmSubsufeoeSewage04osa$ye6am Page 2of17 Commonwealth of Massachusetts �lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -No for Voluntary Assessments /S � , �� 1"1-2, Property Address Ow ner QN ner's Narrie 14C., /hfomtation Is �� Qo 40required for everyState Zip Code Date of ftectfon page. Ckyfrown B. Certification (corn.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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 pi pe(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 M CMR 16.303(1)(b)that the system is not functioning in a mannerwhich 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 Title 80111cial Ins pection F am SubsWace Sowage Olepaeal System•Page 3017 t9ra•3M 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments/ Po Property Address p nf nor fo ,b ON hers name � od-6 0 required for every A v6 N page. (�crown State T075Fd� Date of s ion B. Certification (coat.) 2. System wfll 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 aseptic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well'". Method used to determine distance: This system passes If the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen Is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other. D) System Failure Criteria Applicable to All Systems: You must Indicate "Yes" or"No"to each of the following for j#Inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool 0 Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth In cesspool Is less than 6"below Invert or available volume is less than'/Z day flow t5m,3M3 TMe8Offidal Ins pecdonF arm Sumeam Sewage DiepW3yorn Page 4of17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments l 4- IZ-01Y lsy --� 4��- Property Address / / owner owner's Narr,e at Is /yf D orequired for every /-4!a,4 NrS me. Ctyrrown J --- State Zip Code Date of KspecWn B. CeMcafion (cont.) Yes No ❑ [R' 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. ❑ L�' Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ [� ny 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 collform 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- 10,000g pd. ❑ The system hdis 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. One,y13 TIOeSCIMCI l IfspeclionForR SuDsunaceSwmQeDIspc*d SyWam•Page$oft7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not/for Voluntary Assessments Property Address A--; ON ner Ow ner's Name Infom atlon is AU 0,2 (' 01 required for every l page. Cgyrrown C7- State Zip Code Date oflbspectidn C. Checklist Check If the following have been done. You must indicate'yes"or"no°as to each of the following: Yes No� ❑ L'�' Pumping information was provided by the owner, occupant, or Board of Health ❑ lJ�' ere 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 is inspection? f . 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 inf ation on the proper maintenance of subsurface sewage disposal systems? e 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 (f any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)(310 CMR 15.302(5)1 D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): ,-? D DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): "•3h 3 Tile 50mod IMPWlan F arM SubMace Sewage DlSPW$PW M Page 80f 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurrace Sewage Disposal System Form -Not for Voluntary Assessments Property Address A d 0W ner ON na's Name Information is vt N f f / &O/ G required for every page. j*frown State Zip Code Date offtpecti6n D. System Information Description: 0 CJy a o Number of current residents: Does residence have a garbage grinder? ❑ Yes Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes 01-�No information in this report.) �, � Laundry system inspected? ❑ Yes E, N Seasonal use? ❑ Yes R "" Water meter readings, if available(last 2 years usage(gpd)):. Detail: Sump pump? ❑ Yes No Last date of occupancy: Date Commercial/IndudAal Flow Conditions: Type of Establishment: Design flow(based on 310 CNI R 15.203)! c3allons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, If available: t9ro-yf s Tine 60ftal trepectlm Form Subuslace SewageDinposal sysmm-Page 7of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subs urface sewage Disposal system Form -Not for Voluntary Assessments YJ . 0V, �s ,c'2 Property Address Cw ner 0 ne s Name information is 4 H It required for every State Zip Code Date of spection page. Rown D. System Information (coat.) 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 Mow was quantity pumped determined? Reason for pumping: Type of S M. 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 VA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (descri be): yj"Sof6dal ImpWoOnF=Subsufm SewmeDtowd SVam•Page Sol17 t5int•3n3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 r / / Property Address / Ow ner ON Ws Name Information is required for every Me. Cily/Town per! State Zip Code Date grinspeetion D. System Information (cont.) Approximate age of all components, date installed(if k own) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes L9'No Building Sewer(locate on site plan): Depth below grade: 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.): Septic Tank pocate on site plan): l� Depth below grade: feet Material truction: 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, Sludge depth: dins-3M 3 Tine 5 Official Im pection F orm SubsufWa Sewage Olsposal%atem-Pape 9 of 17 Commonwoafth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1,5 �o,-is i C4 �r tu 02 mmm Property Address Om nor Inforrrlation is Ow na's Name 3 co(J /6 /r' kv requiredforevery _. ! Ao t f �c _ page. Cky/town 011 State Zip Code Date of a tan D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): '17 J o o[ l J�•'� C �`i a rr Grease Trap (locate on site plan): Depth below grade: feet Material of construction: jl ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): i. Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distancefrom bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Ons-3M3 T1050fficial lnspwdonForm Subsufaos SevageDlapasal S)Vam•Page iOd 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments l5 i 0//5 l de- Aa- Property Address o'! Cw ner ONnees NameInformallon Is required for every --.----- page. �yfrown �1' state Zip Code We df 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 worldng 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 TIoe50MCid tre dwForm SuEaufece eDl 6 m• •lid 17 On•Y13 � 5� � � � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for voluntary Assessments ftperty Address h Infvo�n is Ow ner s Name N '-e ad e O/ /6 / required for every State Zip Code fie te o ns pection page. CrlyRown D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): — Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): �b Shci �s Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No' Alarms in working order. ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.),. •If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS)(locate on site plan, excavation not required): 9 SAS not located, explain why: dinsy13 Tile 6OMOW trspac&nFarm Subsurfaoe SevaDeDigmW Sysmm•Page 12 a 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments or*S� Properly Address \V�/ Ow nwr ners Name /�f Mormatbn b requtreedtorevery F✓1✓1!f 1" //4 dd (ao page. W Town We Zip Code Date of ftPection D. System 1 formation (cunt.) Type: �'^ "z J 1- - ❑ leaching pits number. ❑ leaching chambers number. ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovativetaltemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): — 6 / O vl N i N 5.� I CI PG✓1 , �:4 0'e- 0.7 2 '�o, / eve t, .4'j —Z: '4 V-/ f�A ✓1 a✓t C 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 Gns•Y13 TW950ftd ftpeclon Fortrt Subeulwe Seweg9 Diepm Sys*M-Page 13 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal Sys4e Form -Not for Voluntary Assessments IS Property Address oaf ner ow rWs Name Momeftedfo is required for every 141-7 page. 5Wy wn State Zip Code We&Inspection D. System Information (coat.) 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.): Ons•Y13 TWO60f6dal Irx pec6m F arn[Subsufaoe SerapeOlepaeal 3Ystam•Pepe 14 d 17 'L � commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address of Ow ner Ow Ws Name aifornertion is �,fZ/ required for every page. (2ylrown State Zip Cade We Wnspectfon D. System Information (coat.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to nhanEd-sketch manent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate ater supply enters the building. Check one of the boxes below.in the area below ❑ drawing attached separately WAC w 01 Q Too f - LC Aa% i Mrs-3M 3 rifle 50Mdel Impectan Form Subm0ace Snape Dispasel System-Page 15 d 17 JLN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not/for Voluntary Assessments _ I/_�?r'7�S �✓2 �r =� Roperty Address ON nor ON s Mame information is required for every / Z/Z: page. Cdy/rown State Zip Code Rate of D. System Information (cost.) Site Exam ❑ Check Slope ❑ Surface water T� ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water. 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 Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: =muescribe w you established the high ground water elevation: D C w-r•2 o ✓'� o� -��-�//f,�.,�( S o �e to`✓ �•S /.S /J1Q0 l�E � , f /� ro Before filing this inspection Report, please see Report Completeness Checklist on next page. j t9ro•3M3 T1Ve60Mc1d tn+pea00nForm$UbSWWe SewepeDiapesW S)ftm•Pepe 16 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form1_ -Not for Voluntary Assessments property Address Ov rw Is An rler's I�rne 4 ��forevery G vt 4 is � Gb16 O/ Rage. CUylfown Zip C� We bipectbn E. Report Completeness Checklist M Inspection Summary: A, B, C, D, or E checked Ly kispwtion Summary D(System Failure Criteria Applicable to All Systems)completed em k*r mation—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate Ile 9 *'513 TM@ 5 otkW N8PWGM Fam SUbUfF O sWA100 SOMM.asp*n d 17 TO:"N.OF BARNSTABLE LOCATION �� _2),Of SEWAGE # VILLAGE rl ASSESSOR'S MAP & LOTEf e f / ",)A',VC1,-,es A'C O INSTA&iffiR'S NAME&PHONE NO. SEPTIC TANK CAPACITY � /�SPZ-c 76� 4 LEACHING FACILITY: (type) (size) NO.OF BEDROOMS i BUILDER OR OWNER C do jAo ,off �A, SS- �S� FF-DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by w � �^ 6`� � � ® '� � � ® �;''r � �j \ ��. '� , � _ � �- :� ` M vim. yJ�" f • .f-. •r, �` . -- - _- ,� TOWN OF BARNSTABLE LOCATION /S�arl�<.�e d�� SEWAGE # VILLAGE ' ,>/4444/S ASSESSOR'S MAP & Lo4a'V INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /Sz-o Ga.L LEACHING FACILITY: (type) -404 (size) /o>Z.10 104�a NO.OF BEDROOMS _3 BUILDER OR O R �0 G6a It ~~ PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or witt"200;feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by B�� 1 ti O VJ c.J k W r� 7 1. No. / '" Fee J r✓' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ZIppYication for atgo.5al *pgtem Conotruction Permit Application for a Permit to Construct( )Repair(v)Upgrade( )Abandon( ) L�SComplete System ❑Individual Components Location Address or Lot No. /y-C Owner's Name,Address and Tel.No. Assessor' ap/Pazc Amll'y � Installer's Name,Address,an4 Tel.No. Designer's Name,Address and Tel.No. 7?/ I�99 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder Other Type of Building e4 ee& No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow �'/� gallons per day. Calculated daily flow 3 36 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank ` ®® Type of S.A.S. Description of Soil V r3�X Z Nature of Repairs or Alterations(Answer when applicable) < /-(e —Zr IzWell— Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued y thi jar of Health. / Q Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued �.r� 4� _. Fee !✓.1 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLEs MASSACHUSETTS ZippYication for Migpogar *pgtemc Congtruction Permit Application for a Permit to Construct( )Repair(Y)Upgrade( )Abandon( ) o omplete System ❑Individual Components Location Address or Lot No. ,S— /� �f f Owner''ssp Name,Addresss hand Tel.No. Assessor's Map/Parcel �' a /5 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 7?/ ?3W Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(_/_0 Other Type of Building 65 ,ACC No.of Persons Showers( ) Cafeteria( ) w Other Fixtures Design Flow /SG' gallons per day. Calculated daily flow 3'38 gallons. Plan`Date Number of sheets Revision Date Title Size of Septic Tank I"tf q Type of S.A.S. g. Description of Soil /©,1K 3�X Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation,until a Certifi- cate of Compliance has been issued b thi B d of Health. / `��� Signed Date / Application Approved by Date / Application Disapproved for the following reasons Permit No. �' `/� Date Issued f ------ THE COMMONWEALTH OF MASSACHUSETTS Z- BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( v7 iJpgraded( ) Abandoned( )by B/r ® � t.. ,0 at ,! A"/ has been constructed in accor n e with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer & I Designer The issuance of this a shall no/� e c��strued as a guarantee that the sys r"'unction as desgfned. ( �! Date f l { Inspector .ruff.19f= tt 3.- -----�—,,.� ---------------------'---Q----�---- No._- �a G ! "'© Fee �'^✓ �—� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLEs MASSACHUSETTS Mizpogar 6pgtem Conztruction Permit Permission is hereby granted to Construct( ) epair( V<Upgrade( )Abandon( ) System located at ` Je— OT L' �� S and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this t. sue'^ Date: �� /� ram`" Approved by l 1 M" NOTICE: This Form Is To Be-Used For the Repair Of Failed Se tic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PULNEIT(WITHOUT DESIGNED PLANS) L AW�Rr- f Bl�fDCo / , hereby certify that the application for disposal works construction permit signed by me dated ///Z/Q,f concerning the property located at l ,�ar�s�a�c, �T. meets all of the foilowina criteria: V/ The ailed system is mannered=nneced to a esdennzi dweiing oniv. :here are no cornmermai or-,usness / uses associated with the dwe:ling. �+ i ne sail is c!assir ed as C�.5 i=d:he s e=.-iancn:ate s mess than or=_uai :c 5 minutes xf mcal ne:e are no welands-within 00 'er:cf±e crcc_cse tic sysem :here are no private wei?s within '-0 term of he:romsed se--tic srsiem �✓ .here is no ince3se in low and/or:.hang.in liseproposed �1 7he:e are no variances recuesed or need. The bottom of the proposed leaching aclity will not be located less than nve er:above-he ma.,dmum adjusted groundwater table tie-ration. F,44ust the paundwarer mbie king the-F mptcr r / method when apolicablel b� If the S-AS. will be located with:10*er:of any vegetated wedands. the bottom of the prcncszr leaching facility will not be located less than fourteen(14)term cn above the a-amum adiuser groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) 3 rd B) G.W.Elevation le 1 the MAX.High G.W.Adjustment DUTERENCE BETWEEN A and B ° 9 SIGNED DATE: j/l/W [SlMMh proposed play of system on bKkJ. ¢hem hwerCwt Ll 1G�'x 3�'�` z i I I ;II i vjev 1 fol ' ; I , I i TOWN OF L ARNSTABLE LOCATION /� ���r�< '��� �� — SEWAGE # ! (�7��� VILLAGE ���%'��S ASSESSOR'S MAP & LOT O tO I INSTALLER'S NAME$PHONE NO. SEPTIC TANK CAPACITY /s71a z b L LEACHING FACILITY: (type) %o � � (size) NO.OF BEDROOMS BUILDERO R A, G-��/P , COMPLIANCE DATE: PERIvIITDATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility �> Feet i Private Water Supply Well and beaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) !�!� Feet Furnished by 71 1%i COMMONWEALTH OF MASSACHUSETTS Z F EXECUTIVE OFFICE OF ENVIRI jNMENTAL AFFAIRS b � a DEPARTMENT OF ENVIRONMENTAL PROTECTION 0, .. 350 MAIN STREET `p sa WEST YARMOUTH,MA,ARCE1_ 508-775-2800 LZtx-1L;;U LOT TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION `' MAP 288—PARC 069 }, Property Address: 15 PORTSIDE DRIVE _ HYANNIS,MA 02601 0 Owner's Name: MCGONIGLE,HENRYa . Owner's Address: 15 PORTSTUE DRIVE 1 n HYANNIS,MA 02601 Date of Inspection APRIL 5,2005 Ln � w Name of Inspector:(please print) JAMES D. SEARS r-- Company Name: A&B Canco cv r,y Mailing Address: 350 Main Street West Yarmouth,MA 02673 Telephone Number: 508-775-2800 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 Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: � Q 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 tot he buyer,if applicable,and the approving authority. Notes and Comments ....This report only describe;conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 1 r Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 15 PORTSIDE DRIVE HYANNIS,MA 02601 Owner: JAMES D.SEARS Date of Inspection: APRIL 5,2005 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: N/A 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 complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping mr ru 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: Title 5 Inspection Form 6/15/2000 2 Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 15 PORTSIDE DRIVE HYANNIS,MA 02601 Owner: JAMES D. SEARS Date of Inspection: APRIL 5,2005 C. Further Evaluation is Required by the Board of Health:N/A 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 functioningin a manner which will protect public health safe an p p safety d 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 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 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 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: Title 5 Inspection Form 6/15/2000 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 15 PORTSIDE DRIVE FIYANNIS,MA 02601 Owner: JAMES D. SEARS Date of Inspection: APRIL 5,2005 D. System Failure Criteria applicable to all systems: N/A 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 %7— 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 leaching is less than 6"below invert or available volume is less than%day flow ,7— 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 N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone 1 of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A 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 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: N/A To be considered a large system the system must service 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 vvidun 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 H 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 is 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. Title 5 Inspection Form 6/151'2000 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 15 PORTSIDE DRIVE HYANNIS,MA 02601 Owner: JAMES D. SEARS Date of Inspection: APRIL 5, 2005 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)has been determined based on: Yes No ✓ Existing information. For example,a plan at the Board of Health. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)(310 CMR 15.302(3Xb)] Title 5 Inspection Form 6/15/2000 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 15 PORTSIDE DRIVE HYANNIS,MA 02601 Owner: JAMES D. SEARS Date of Inspection: APRIL 5,2005 FLOW CONDITIONS RESIDENTIAL Number of Bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CNM 15.203(for example: 110 gpd x#of bedrooms: 220 Number of current residents: 1 Does 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): YES Seasonal use(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): 2005—700 GAL/2004&2003-150 GAL Sump pump(yes or no) NO Last date of occupancy: PRESENT COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): 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: N/A 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 ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or noKif 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 copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 1999 PERAUT#99-765 Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 i; OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 15 PORTSIDE DRIVE HYANNIS,MA 02601 Owner: JAMES D. SEARS Date of Inspection: APRIL 5,2005 BUILDING SEWER(locate on site plan): ✓ Depth below grade: 6" Materials of construction: Cast iron ✓ 40 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 onsite plan): ✓ Depth below grade: 7" Material of construction: concrete 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: 1500-GALLON PRE-CAST Sludge depth: 8" Distance from top of sludge to the bottom of outlet tee or baffle: 22" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle: 16" How were dimensions determined: ASBUILT&TAPE Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): MAIN TANK AT WORKING LEVEL,INLET TEE—OUTLET TEE. NO SIGN OF OVERLOADING OR LEAKAGE. GREASE TRAP(located on site plan) N/A 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.): Title 5 Inspection Form 6/15/2000 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: 15 PORTSIDE DRIVE HYANNIS,MA 02601 Owner: JAMES D. SEARS Date of Inspection: APRIL 5,2005 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.): 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.,): D-BOX IS 16"X 16"—I I"BELOW GRADE,BOX IS CLEAN&SOLID. NO SIGN OF OVERLOADING OR SOLID CARRY OVER. PUMP CHAMBER: N/A (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.): ' Title 5 Inspection Form 6/15/2000 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: 15 PORTSIDE DRIVE HYANNIS,MA 02601 Owner: JAMES D. SEARS Date of Inspection: APRIL 5, 2005 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: 4—10'X 30'X 2' 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.) LEACHING IS FOUR INFILTRATORS,20"BELOW GRADE.INSPECTORS PORT AT 10",2"WATER. NO SIGN OF OVERLOADING OR SOLID CARRY OVER. CESSPOOLS: N/A (cesspool must be pumped as part of inspectionXlocate 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: N/A (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.) Title 5 Inspection Form 6/15/2000 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 15 PORTSIDE DRIVE HYANNIS, MA 02601 Owner: JAMES D. SEARS Date of Inspection: APRIL 5, 2005 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. jv'SF£ cl d.F S 7. Title 5 Inspection Form 611511_000 10 Page 11 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 15 PORTSIDE DRIVE HYANNIS, MA 02601 Owner: JAMES D. SEARS Date of Inspection: APRIL 5, 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to no groundwater 9. 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: 7 Observation 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 DUG TEST HOLE 9'NO WATER. TEST HOLE 5' BELOW BOTTOM OF LEACHING. Title 5 Inspection Form 6/1 5/20110 11