Loading...
HomeMy WebLinkAbout0017 WOLLEY ROAD - Health 17 Worley Road. Hyannis P A = 270 158 1 it m Commonwealth of Massachusetts 'Y �"j �� mD45t) Title 5 Official Inspection Form �o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ..a t 17 Wolley Road Property Address Greg Nowak Owner Owner's Name information is required for Hyannis MA 02601 January30, 2012 _. every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. Company Name Q 189 Cammett Road Company Address Marstons Mills MA 02648 "KI City/Town State Zip Code 508-428-1779 SI 12855 Telephone Number License Number B. Certification CD fi,1 I certify that I have personally inspected the sewage disposal system at this address and that the v _ 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�!,(31,0 CMR 15.000). The system: �- ® Busses ❑ Conditionally Passes ❑ Fails C) U— '' ❑ Needs Further Evaluation by the Local Approving Authority ri anuary 30, 2012 Job# 12-11 pector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Wolley Road Property Address Greg Nowak Owner Owner's Name information is Hyannis MA 02601 January 30, 2012 required for y y every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 1 ❑ 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 15ins-11/10 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 *„a 17 Wolley Road Property Address Greg Nowak Owner Owner's Name information is Hyannis MA 02601 January 30, 2012 required for y ry every page. Cityfrown 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: Tank was not in need of pumping at time of inspection leaching system was dry. 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. II *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): l5ins•11l10 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Wolley Road Property Address Greg Nowak Owner Owner's Name information is Hyannis MA 02601 January 30, 2012 required for y every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of.Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool y ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow t5ins.11110 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 17 Wolley Road Property Address Greg Nowak Owner Owner's Name information is required for y H annis MA 02601 January 30, 2012 - every page. City/Town 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 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well 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. 15ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 17 Wolley Road Property Address Greg Nowak _ Owner Owner's Name information is Hyannis MA_ 02601 January 30, 2012 required for � _______ y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 0" 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? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank had liquid only, no solids. Liquid level was at bottom of outlet invert and tees were intact. 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•11/10 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 17 Wolley Road _ Property Address Greg Nowak Owner Owner's Name information is Hyannis MA 02601 January 30, 2012 required for y ry every 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 il Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No solids or high stains present. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Wolley Road Property Address Greg Nowak Owner Owner's Name information is Hyannis MA 02601 January 30, 2012 required for Y ry every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: Four Infiltrators. ❑ 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.): Interior of infiltrators were video inspected with no standing water or evidence of surcharge found. 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 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Wolley Road Property Address Greg Nowak Owner Owner's Name information is required for y H annis MA 02601 January30, 2012 - every page. Cityfrown 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 for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 i 15ins.11/10 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 6 of 17 .1 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ., 17 Wolley Road Property Address Greg Nowak Owner Owner's Name information is required for Hyannis _MA 02601 January 30, 2012 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Unknown Last date of occupancy: Date Commercial/Industrial Flow Conditions: I Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: — t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 a - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Wolley Road _ Property Address Greg Nowak _ Owner Owner's Name information is Hyannis MA 02601 January required for Y — Y 30, 2012 every 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: None available Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping.- Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): l5ins•11110 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 8 of 17 :. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Wolley Road Property Address Greg Nowak Owner Owner's Name information is Hyannis MA 02601 January required for Y _ y 30, 2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Compliance Date: 3/29/00 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 1' 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 (locate on site plan): Depth below grade: 6 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10.5' long x 5.8'wide- 1500 gal. Sludge depth: 0 11 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Wolley Road Property Address Greg Nowak Owner Owner's Name information is Hyannis MA 02601 January required for y 30, 2012 every page. Cityrrown 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 t51ns•11/10 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 17 Wolley Road _ Property Address Greg Nowak Owner Owner's Name information is Hyannis MA 02601 January 30, 2012 required for Y y every page. Citylrown 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.): I� t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts ' roTitle 5 Official Inspection FoNN0N Subsurface Sewage Disposal System Form ' Not for Voluntary Assessments 17VYqlley Road — Property Address ���--------------- ------ -------- Gna Nowak mwne, ���� ------------- ------------'------------- owne,�awamo mwnmanvn/s required for Hyannis __�____________ MA 02601 January 30 2012 � every page. �«p/»w» State Zip Code Date mInspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal oyabam, including ties to � at least two permanent reference landmarks or benchmarks. Locate all wells within 100feet Locate � where public water supply enters the building. Check one of the boxes below: ER hand-sketch m the area below El drawing attached separately 40 17 � � � � ,,a"~. � Service � Wolley Road � � � �w. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Wolley Road Property Address Greg Nowak Owner Owner's Name information is Hyannis MA 02601 January required for Y y 30, 2012 every page. City/Town 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: 20+ 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: USGS top[o map and town GIS. You must describe how you established the high ground water elevation: Town groundwater contour map shows water at el. 25 and topo map shows property at el. 50. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 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 17 Wolley Road Property Address Greg Nowak Owner Owner's Name information is Hyannis MA 02601 January required for Y 30, 2012 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 COMMONWEALTH OF MASS ACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION t TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 17 Wolley Road Hyannis Owner's Name: Marcelo Souza Owner's Address: I Marc Drive,Unit 3 Plymouth,MA 02360 �U Date of Inspection: 11/17/2006 Name of Inspector: (please print) Patrick T. Sullivan Company Name: Ready Rooter Mailing Address: P.O. Box 371 Sandwich,MA 02563. Telephone Number: (508)888-6055 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 Authority Fails Inspector's Signature: /� � Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or --; DEP)within 30 days of completing this inspection.If the system is a shared system or has a designI flow of�0;000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office Kthe 7= DEP.The original should be sent to the system owner and copies sent to the buyer, if applicablepd the app ovinE authority. <t > Notes and Comments _= 21 T.- Fr r co F ****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. 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 17 Wolley Road Hyannis Owner: Marcelo Souza Date of Inspection: 11/17/2006 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _-ZI 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"Co ditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or ,epair,as approved by the Board of Health,will pass. J f Answer yes,no or not determined (Y,N,ND)in the f for the following statements. If"not determined"please explain. f J The septic tank is metal and over 20 years olq* 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 bleak 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 r` distribution box is leveled or replaced ND explain: J' The system required pOnping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: J 1 1 Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 17 Wolley Road Hyannis Owner: Marcelo Souza Date of Inspection: 11/17/2006 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the oard 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 det mines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner wh' will protect public health,safety and the environment: _Cesspool or privy is within 50 fee of a surface water _Cesspool or privy is within 50 f et of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Sup_p�l�i ,if any)determines that the system is functioning in a manner that protects the public health,safety "d environment: _The system has a septic tank and soil absorption system(SAS)/dnd the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. f The system has a septic tank and SAS and the SAS is wdin a Zone 1 of a public water supply. _The system has a septic tank and SAS and theZSS dwithin 50 feet of a private water supply well. _The system has a septic tank and SAS and ths less than 100 feet but 50 feet or more from a private water supply well". Method used to detedistance "This system passes if the well water analysis;performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicate"that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate rogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the 711lysis must be attached to this form. 3. Other: / Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 17 Wolley Road Hyannis Owner: Marcelo Souza Date of Inspection: 11/17/2006 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 and overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than %2 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. 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 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] 7 0(Yes/No)The system fails. I have determined that one or more of the above 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 ith 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 th criteria above) yes no the system is within 400 feet of a surface drinki water supply the system is within 200 feet of a tributary tg/a surface drinking water supply the system is located in a nitrogen sensit*Ie 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 i Section E the system is considered a significant threat,or answered "yes"in Section D above the large system s failed.The owner or operator of any large system considered a significant threat under Section E or faile 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. t i r Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 17 Wolley Road Hyannis Owner: Marcelo Souza Date of Inspection: 11/17/2006 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 than 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: Yes No ✓ _ Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] r Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 17 Wolley Road Hyannis Owner: Marcelo Souza Date of Inspection: 11/17/2006 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 C.zP, , Number of current residents: a Does residence have a garbage grinder(yes or no):1J� Is laundry on a separate sewage system(yes or no):.J[if yes separate inspection required] Laundry system inspected(yes or no): — Seasonal use:(yes or no):2o Water meter readings, if available(last 2 years usage(gpd)): �" i ©cam Q�, Sump Pump(yes or no):, � Last date of occupancy: COMMERCIALANDUSTRIAL Type of establishment: L Design flow(based on 310 CMR 15.20 gpd Basis of design flow(seats/persons/s .ft.etc.): Grease trap present(yes or no): / Industrial waste holding tank prent(yes or no):— Non-sanitary waste discharged4o the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/u§�. OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no):&-1- If yes,volume pumped: Qallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM tic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool —Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) T Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of inforation: Were sewage odors detected when arriving at the site(yes or no):,aa<5 f Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 17 Wolley Road Hyannis Owner: Marcelo Souza Date of Inspection: 11/17/2006 BUILDING SEWER(locate on site plan) Depth below grade: %S " Materials of construction:_cast iron 40 PVC_other(ex lain): Distance from private water supply well or suction line: � . Comments(on condition of joints,venting,evidence of leaka e,etc.): SEPTIC TANK: (locate on site plan) Depth below grade: 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: Sludge depth: Z)" Distance from the top of sludge to bottom of outlet tee or baffle: 22 Scum thickness: I" Distance from top of scum to top of outlet tee or baffle: r Distance from bottom of scum to bottom of outlet tee or baffle: _ How were dimensions determined? ..,e,� Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): n \ V �L" ram. �u ham' L-! u.,�C. Lr'L�r W� GREASE TRAP:_(locate on site plan) Depth below grade: Material of construction:_concrete metal_fiberglass_polyethylene_other (explain): f Dimensions: Scum thickness: Distance from top of scum to top/of outlet tee or baffle: Distance from bottom of scum�o 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.): 1' l` Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 17 Wolley Road Hyannis Owner: Marcelo Souza Date of Inspection: 11/17/2006 TIGHT or HOLDING TANK: (tank must be pumpe4,et time of inspection)(locate on site plan) Depth below grade: ���' Material of construction:_concrete_metal;Z06erglass__polyethylene_other(explain): ,r Dimensions: f� Capacity: gallons �f Design Flow: gallon ay Alarm present(yes or no): Alarm level: Alarm in woyl(ing order(yes or no): Date of last pumping: f Comments(condition of alar-1nd float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(not if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): �+ PUMP CHAMBER: (locate on site pl�rl) r Pumps in working order(yes or no):�.rr Alarms in working order(yes or no): Comments(note condition of pump clamber,condition of pumps and appurtenances,etc.): l Page 9 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 17 Wolley Road Hyannis Owner: Marcelo Souza Date of Inspection: 11/17/2006 SOIL ABSORPTION SYSTEM(SAS):_Z(Iocate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: 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.): v, A• CESSPOOLS: (cesspool must be pumpe 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 i ow(yes or no): Comments(note conditio 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 hydrae is failure,level of ponding,condition of vegetation,etc.): .i f I Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 17 Wolley Road Hyannis Owner: Marcelo Souza Date of Inspection: 11/17/2006 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building. 1 _ I I I I 1 I I i 1 � 7 l f - Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 17 Wolley Road Hyannis Owner: Marcelo Souza Date of Inspection: 11/17/2006 SITE EXAM Slope A&) Surface water NC-11 Check cellar Shallow wells Estimated depth to groundwater ZJ} feet Please indicate(check)all methods used to determine the high ground water elevation: _ZO-'btained 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 the local Board of Health-explain: Checked with local excavators, installers-(attach documentation) _tZAccessed USGS database-explain: TF3 r,,.4,%ff_._,c, _. cow— You r^must describe how ou established the high ground water elevation: 1J0�'•^.�� _ .•+,c ,�3L r-�-O � ,a �. �x �e-.r �m�v"�c5 ca►Ti Aca N'C"' VW.�� COMMONWEALTH OF KASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 17 6vo Ile RECEIVED Owner's Name:� � r Owner's Address: ..9&4L1&ftj5j MA 40 JUN 0 2 2004 Date of Inspection• • / / TOWN OF BARNSTABLE Name of Inspector: pl print) i c nt) a d(d 44 HEALTH DEPT. Company Name: c it a lute h ts 6, Mailing Address: 6 MAP' 6 q/ Telephone Number: 6-0 —3ts'T 76oP .ARCE4 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 15340 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: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address lkow the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 6f I l OFFICIAL INSPECTION FORM="NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE MSPOSAL SYSTEM INSPECTION FORM f PART A CERTIFICATION(continued) Property Address: Owner ?/ Date of Inspection: 6 o Inspection Summary: Check A,B,C D or E 1 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 to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the followin eats.If`snot determined"please explain. The septic tank is metal and over 20 years old*or the c tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or failure is imminent System will pass inspection if the existing tank is replaced with a complying septic tank ved by the Board of Health. *A metal septic tank will pass inspection if it is stru sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old' le. ND explain.- Observation of sewage backu or break out or high static water level in the distribution box due to broken or obstructed pipes)or due to a bro settled or uneven distrilywon box.System will pass inspection if(with approval of Board of Health): broken pipe(s)amxcpb=d obstractimisremoved distri6oiod box is k-&Ied or replaced ND explain: The required primping more than 4 times a year due to broken or obstructed pipe(s).The system.will pass insp on if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CCERTIFICATION(continued) Property Address• 17 e JT 42 �. Owner: Aeelwoo, Date of Inspection: C/.b y C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if a 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 1 030)(b)that the system is not functioning in a manner which will protect public health,safety an a 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 t marsh 2. System will fail unless the Board of Health(and Public Wa Supplier,if any)determines that the system is functioning in a manner that protects the public hea safety and environment: _ The system has a septic tank and soil absorptions m(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water s ly. The system has a septic tank and SAS and SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS d the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and S and the SAS is less than 100 feet but 50 feet or more from a private water supply well**.Meth to determine distance "This system passes if the we ter analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic ompounds indicates that the well is free from pollution from that facility and the presence of ammonia ogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are tri d.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM" —NO'P FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DIWKWAL.SY3TEM INSPECTION FORM ' PART A- CERTEnCATION(continued) Property Address l7 Kt s� iS Owner:. �r Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for aIl inspections: Yes 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 distnbution 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'/a day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ Any portion of a cesspool or privy is within a Zone 1'of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.(This system passes if the well water analysis, performed at a DEP certified laboratory,for aofterm bacteria and volatile organic compawfids 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 dean 5 ppm,provided that no other.faiiure criteria are triggered.A copy of the analysis must be attached to this form.] kM (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 fans.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 flow of 10,000 gpd to 15,000 gpd, You must indicate either"yes"or"no"to each ofthe following (The following criteria apply to large systems in.addition to the above) yes no the system is within 400 fed of a surface . g water supply _ — the system is within 200 feet of utary to a surface drinking water supply _ the system is located in trogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public w supply well If you have answered"y to any question in Section E the system is considered a significant threat,or answered { "yes"in Section D e the large system has&Hed.The owner or operator of any large system considered a. significant threat der Section E or failed under Section D shall upgrade the system in accordance with 310 CM 15.304.The em owner should contact the appropriate regional office of the Department. A Page 5 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR M PART B CHECKL`IST Property Address: 0 C Owner: Date of Inspection: 6 Check if the following have been done You must indicate"yes"or"no"as to each of the following: Yes No p� pumping information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out' the previous two weeks? . i Has the system received normal flows in the previous two-week period? — Have large volumes of water been introduced to the system recently o�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 hack 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 shidge 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: 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 unacceptab_ le)[310 CMR 15302(3)(b)] S .Page 6 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: /7 a i Owner: / 4 Date of Inspection: Q FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):. Number of bedrooms(actual): 3 DESIGN flow based on 310 CMA,15.203(for example: 110 gpd x#of bedrooms): Number of current residents: 4. G Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system or or no):� f if yes separate inspection required] Laundry system inspected es or no):® Seasonal use:(yes or no):J Water meter readings,if ay�ailable(last 2 years usage(gpd)): Sump pump(yes or no):N,_ ,/ Last date of occupancy: G rI i COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Basis of design flow(seats/persons/sgft,e . Grease trap present(yes or no):_ Industrial waste holding tank p t(yes or no): _ Non-sanitary waste discharg the Title 5 system(yes or no):_ Water meter readings,if Table: Last date of occupan e: OTHER(des ): GENERAL INFORMATION Pumping Records 6 Source of information: t ti S t l�G _J n. Was system pumped as part of th inspecri no(ys or no): 4 If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM �, Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate a of a c mppj�ennts date ipstalled(if known)and source of information: OD v �(�( Were sewage odors detected when arriving at the site(yes or no): 100 6 Page 7 of i,1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: / Ie cc ac S Owner: Ige Date of Inspection: 6 / O� BUILDING SEWER(locate on site plan) Depth below grade: �J Materials of construction: cast iron -f 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 on site plan) Depth below grade: 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: Sludge depth: v Distance from top of Mudge to bottom of outlet tee or.baffle: C3 Scum thickness: / G� Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom Qf_outlet tee or affle: How were dimensions determined: /If B&Wt Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as re t to out invert,evidence of GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction: concrete metal erglass,polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of let tee or baffle: Distance from bottom of scum to ttom of outlet tee or baffle: Date of last pumping: Comments(on pumping r mmendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet inve evidence of leakage,etc.): 7 Page-8 of l 1, OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C M INFORMATION continued SYSTEM (continued) Property Address. 17 0.0( 5 S Owner: Date of Inspection: !o HOLDING TANK: tank must be at time of inspection)(locate on site plan) TIGHT or HOLD ( P Depth below grade: Material of construction: concrete tal fiberglass _polyethylene other(explain): Dimensions: Capacity: ons Design Flow: allons/day Alarm present(yes or no)- Alarm level: arm in working order(yes or no): Date of last pump' Comments(con ' on of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(iocate on site plan) Depth of liquid level above outlet invert �.OM Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage int or out of box,etc.): r Log bps,.`, �t2� 0 Q..&& Tce W "S(4 tL, PUMP CHAMBER: (locate a plan) Pumps in working order or no):. Alarms in worldng 1(yes or no): Comments(note ditif pump chamber,condition of pumps and appurtenances,etc.): ` t g Page 9 of l I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ��SYSTEM INFORMATION(continued) Property Address- ,//" J.t Owner: Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type teaching pits,number: leaching chambers,number. leaching galleries,number leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number. innovativelalternative system Typetname of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc. ): vG ` S k 9 ►A rw`M s tsvr �o y O S.7 *4 � � f c &Q PIC!JV% t CESSPOOLS: (cesspool must be pumped art 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: I Materials of construction: Indication of groundw r inflow(yes or no): Comments(note co lion 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 co Lion of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): i 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: I 4,GC 12J -114 Owner. Y- Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply ebters the building. � c� Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C // SYSTEM INFORMATION(continued) Property Address: 17 o61e� Owner: 1% rR Date of Inspection: IL OG SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water dSS_feet Please indicate(check)all methods used to determine the high ground water.elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers(attach documentation) �! Accessed USGS database-explain: You must describe how you established the high grow water a evation: ' i1 TOWN OF BARNSTABLE LOCATION J ( IoJLkoczd, SEWAGE 9.T/IS10 VILLAGE ,S AS SSOR'S MAP&PARCEL D���,4ieS AME&PHONE NO. �I777 SEPTIC TANK CAPACITY 4, S LEACHING FACILITY:`(type) :Tn A (size) NO.OF BEDRO MS �1 OWNER D o— PERMIT DATE: C ATE 1 Z 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 \ \ h k h •+ k ♦ \ 4 \ h \ \ 4 4 4 \ ♦ \ h + \ \ \ \ 4 ♦ h \f4J♦f\ 4r\J\J\f\f\�' 4 fh \f\Jhf\ 4J+•l4 fy,f♦I♦^` ! !•+ f i f f+ f / I f+ f /+f ! f ! \ h 4�♦ 4+\ k \f\ 4� k \ \�4 4 4r\ kr4 4 \ 4 \ +, ' \ \ \ \ h h 4 \ 4 4 \ \ h 4 \ \ ♦ \ 4 4 h 4 k 4 4 4 4 4 4 4 1 19 40 17 Water Service TOWN OF BARNSTABLE LOCATION �''Z CSL�q�`+Gvl �o �, SEWAGE# - ( 'Z VILLAGE ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. M1 Q, Can e_ SEPTIC TANK CAPACITY LEACHING FACILITY: (type)1�. ��-i dr�'�d.7'� (size) _L4 - // "A-T NO. OF BEDROOMS OWNER PERMIT DATE: COMPLIANCE DATE: Q 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 ,�,,� ,,c i as..y.�Vim, G�u�.'�SC•.s� O'y iq p/ LAY tV Q � W 14 _ - P' TOWN OF BARNSTABL® l LOCATION D EWAGE # / .-VILLAGE--' f��/.Uyw/ S ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. A247n C ge&, �'�a SEPTIC TANK CAPACITY .15 0 LEACHING FACILITY: (type) 7e—z&A-4 7aOf S (size) NO.OFBEDROOMS BUILDER OR OWNER , PERMITDATE: COMPLIANCE DATE: ©� Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by \_ � � � � 1� y .. � 7� V+ 6� W � c � � �' f..� N per. _'a I o - ,. � , ` =�c; . '�� TOWN OF BARNSTABL® � LOCATION Yft�sSWAGE # / 2 VILLAGE- flkaryi//I S _ASSESSOR'S MAP & LOT 70— INSTALLER'S NAME&PHONE NO,. ^" SEPTIC TANK CAPACITY LEACHING FACILITY: (type) L/Y{r /<A/OX S (size) /� .25� NO.OF BEDROOMS BUILDER OR OWNER ICOMPLIANCE DATE: =62 PERMITDATE: . Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility)jq Feet Furnished by L . 77 " No.2 any ��7 Fee��_�`� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: cr/ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipprication for Migonl *p5tem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade Y'J'Abandon( ) .Complete System O Individual Components Location Address or Lot No. Owner's Name(,Address and Tel.No. Assessor's Map/Parcel D:70_.J S8 >> CC,V CouV Installer's Name,Address,and Tel.No. v Designer's Name,Address and Tel.No. \'S w Type of Building: Dwelling No.of Bedrooms :72 — Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures C Design Flow ���U gallons per day. Calculated daily flow 73 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank I Type of S.A.S. 4k-1 Description of Soil Nature of Repairs or Alterations(Answer when applicable) itsIL kAl 1a ✓ci"-C�OGc.SU � 4a-1-9, 42 SSA", 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 Environm ntal Code and not to place the system in operation until a Certifi- cate of Compliance has be e y t 2�e SignedDate Application Approved by Date 21 h n Application Disapproved for the follow g reasons Permit No. _-LGlein 7 Date Issued , r �- No. v "..�. Fee _ o .. u THE COMMONWEALTH OF MASSACHUSETTS ..a'Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZIppYication for �Digoar *p5tem Con!gtruction 3permit Application for a Permit to Construct( )Repair( )Upgrade`,.)Abandon( ) Complete System O Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel �,Go Installer's Name,Address,and Tel.No. 4 Designer's Name,Address and Tel.No. r~ Type of urldi g: Dwelling No.of Bedrooms _ Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures ' Design Flow gallons per day. Calculated daily flow C. gallons. Plan Date J Number of sheets Revision Dat Title Size of SepticJank Type of S.A.S. J �t Description of Soil Nature of Repairs or Alterations(Answer when applicable) � r, I C./ �r � • r/" \ � � � � �GAL , �-. t +.__ �� U rk_ v✓ Date last ipspected: 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-by-t and of Healt �(� Signed ~~ _ Date _ 9 Application Approved by Date Application,Disapproved for th ollow' re sons Permit No. Date Issued ---------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded(�-- Abandoned( )by — at has been constructed in accordance with the provisions of Title i add e for i os ystem Constru 'o ermrt No'� _ dated Installer Designer The issuance of this permit j��rha11 not be construed as a guarantee that the syst ffi will function as detsignAG Date /A .fi �/"1 Inspector ?h t?���f ri Jl. a J/ J r v y si Iv ——————————————————————————————————————— No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS lwiooar *pgtem Construction 3permit Permission is hereby granted to Construct( )Repair( )Upgrade( ,_�andon( ) System located at ct wtA 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 permit. Date: Approved by 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) hereby certify that the application for disposal works construction permit signed by me dated `� —Q� , concerning the property located at V-7 W A` 164 meets all of the following criteria: L4 This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. There are no wetlands within 100 feet of the proposed septic system �• There are no private wells within 150 feet of the proposed septic system 64 There is no increase in flow and/or change in use proposed 6- There are no variances requested or needed. Ce The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] `/• If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: 9 A) Top of Ground Surface Elevation(using GIS information) 5� / B) G.W.Elevation t/c +the MAX. High G.W.Adjustment.(,F _ DIFFERENCE BETWEEN A and B 3v� SIGNED : DATE: [Please Sketch pr posed plan of s ste on back]. NOTICE Based upon the above information, a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:cert a. ,.> Ca ,��.