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HomeMy WebLinkAbout0668 PUTNAM AVENUE - Health 668 yPutnarn Avenue' -- ---- -- — --- A =`039 110 I Commonwealth of Massachusetts W Title 5 Official Inspection Form IT Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ryl 9 P Y rY I`t'� 011 668 Putnam Ave ' ' M Property Address h*t Rachel Andrews 4 Owner Ownn%s Name ; information is required for every Cotuit/ Barnstable MA 02630 1/22/18 ez page. City/Town State Zip Code Date of Inspection L 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 �"/ /,,?go� filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Brett Hickey use the return Name of Inspector key. B&B Excavation " Company Name 14 Teaberry Lane Company Address Sandwich Ma. 02644 Cityrrown State Zip Code (508)477-0653 S113747 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority ` 1/22/18 Inspector's ure 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 bo* VJ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 668 Putnam Ave Property Address Rachel Andrews Owner Owner's Name information is required for every Cotuit/Barnstable MA 02630 1/22/18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: At time of inspection all components appear to be in working order. 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 668 Putnam Ave Property Address Rachel Andrews Owner Owner's Name information is required for every Cotuit/ Barnstable MA 02630 1/22/18 page. City/Town State Zip Code Date of Inspection B. 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. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 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 ,M 668 Putnam Ave Property Address Rachel Andrews Owner Owner's Name information is Cotuit/ Barnstable MA 02630 1/22/18 required for 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 ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•3/13 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 �M 668 Putnam Ave Property Address Rachel Andrews Owner Owner's Name information is required for every Cotuit/ Barnstable MA 02630 1/22/18 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 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. t5ins•3/13 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 M 668 Putnam Ave Property Address Rachel Andrews Owner Owner's Name information is required for every Cotuit/ Barnstable MA 02630 1/22/18 page. City/Town 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): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 668 Putnam Ave Property Address Rachel Andrews Owner Owner's Name information is required for every Cotuit/Barnstable MA 02630 1/22/18 page. Cityrrown 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? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d see below 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Nov-2017 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: l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 668 Putnam Ave Property Address Rachel Andrews Owner Owner's Name information is required for every Cotuit/ Barnstable MA 02630 1/22/18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/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•3/13 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 ' M 668 Putnam Ave Property Address Rachel Andrews Owner Owner's Name information is required for every Cotuit/Barnstable MA 02630 1/22/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1975 Were sewage odors detected when arriving at the site? ❑ Yes ® 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.): At time of inspection building sewer appeared to be in good working order with no sign of leakage. Septic Tank(locate on site plan): 6" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon Sludge depth: 2" t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 668 Putnam Ave Property Address Rachel Andrews Owner Owner's Name information is Cotuit/ Barnstable MA 02630 1/22/18 required for every page. Cityrrown 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 34" � Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" 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.): At time of inspection septic tank appeared to be in working order,baffles present with no sign of back- up.Liquid level equal with outlet invert. Tank is not in need of pumping at this time but should be pumped every 2 years for maintenance. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts F u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 668 Putnam Ave Property Address Rachel Andrews Owner Owner's Name information is required for every Cotuit/ Barnstable MA 02630 1/22/18 page. City(rown 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(expla,in): 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W .Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 668 Putnam Ave Property Address Rachel Andrews Owner Owner's Name information is required for every Cotuit/Barnstable MA .02630 1/22/18 page. CityrTown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): n/a 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): If SAS not located, explain why: 15ins•1113 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 M 668 Putnam Ave Property Address Rachel Andrews Owner Owner's Name information is Cotuit/ Barnstable MA 02630 1/22/18 required for every page. City frown State Zip Code Date of Inspection a D. System Information (cont.) Type: ® leaching pits number: 1 6'x6' ❑ 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.): At time of inspection leaching appears to be in working order with no sign of hydraulic failure. Pit was dry at time of inspection with stain line half way up pit. 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 l5ins-3/13 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 M 668 Putnam Ave Property Address Rachel Andrews Owner Owner's Name information is required for every Cotuit/ Barnstable MA 02630 1/22/18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 r `Cornmonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 668 Putnam Ave Property Address Rachel Andrews Owner Owner's Name information is required for every Cotuit/ Barnstable MA 02630 1/22/18 page. 'Cityaown State Zip Code Date of inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system;including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate where public watersupply enters the building. Check one of the boxes below: Z' hand-sketch in the area below 0 °'drawing attached separately O 0 3b t5ins•3f13 Title 5 Official Inspection Form:Subsurface.Sewage Disposal System-Page 15.of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 668 Putnam Ave Property Address Rachel Andrews Owner Owner's Name information is required for every Cotuit/ Barnstable MA 02630 1/22/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: No Gw 117' 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: prev. insp. reportDate ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Title 5 report on file at BOH. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 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 668 Putnam Ave Property Address Rachel Andrews Owner Owner's Name - information is required for every Cotuit/Barnstable MA 02630 1/22/18 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 k l 2 ,r COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION FC': MAR 2 9 200UqF TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION .AP Ys� � Property Address: b b g Tr1 N W 1 a llei UARCEL. _CH , l0,4 0d t� LOT Owner's Name: o H undo _ Owner's Address: j* 5'0 8 Date of Inspection: o S Name of Inspector: ease print) i G r!� / o Isle, Company Name: &rt/1/i J - T-FG H Mailing Address: PO o X 1,11ex Telephone Number•. oaf 7 - 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 on 15-W of Title 5(310 CMR 15.000). The system: a Passes Conditionally Passes Needs s Further Evaluation by the Local AppxMng Authority Fails Inspector's Signature: &4&- 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 appxpute 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 peck address how the system will perform in the fatnre ender the same or different conditions of use. I Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner. m r orn 1 ✓ Date of Inspection: a-a p r' Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Syste ses: 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 Amy failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: L 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 enfiltration 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 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 willpass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will Pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Ct;2�2 Q 417 u wr q Owner. N r 9 e Date of Inspection: >L-02 g- 0 T C. Further Evaluation is Required by the Board of Health: Conditions e2dst which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: — Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in,a manner that protects the public health,safety and environment: > _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. — The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a Private water supply well**.Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory;for coliform bacteria and volatile organic compounds indicates that the well is free frompollution 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 ibis form. 3. Other. I Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: �(�� �vt h�ivy Owner. ©01673• v�.- � l✓ Date of Inspection: oZ - - O D. System Failure Criteria applicable to all systems: You must indicate`yes"or"no"to each of the following for all inspections: Yes No/' _ ✓✓/Sa&up 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 1 _ _ depth in cesspool is less than 6"below invert or available volume is less than%s day flow Required pumping more than 4 times in the lastyear NOT due to clogged or obstructedpipe(s).Number �of times pumped iAny 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. _ V ACV portion of a cesspool or privy is within 50 feet of a private water supply well. Airy 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. f This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: ('The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface d inking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped- ne II of a public water supply well If you have erect"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 systemin.accordance-with,310.CMI; 15.304.The system owner should contact the appropriate regional office of the Department. 4 I •. • Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address• vr ��!rt►a'� Gd vim_ �j o K ' Owner:/ "/ 4/ 0 c 3� Date of Inspection: 05 . Check if the foll"M have been done.You must indicate`Yes"or"no"as to'each of the following: Y1 1Vo — _ Pumping information was provided by the owner,occupant,or Board of Health _ i/ Were any of the system components pumped out in the previous two weeks Hasthe system received normal flows in the previous two week eek period Have large volumes of water been introduced to the system recently or as part of this inspection yere as built plans of the system obtained and examined?(If they were not available note as N/A) — Was the facility or dwelling inked fbr signs of sewage 1 up V/— Was the site inspected for signs of break out Were all system components,exchedeng the SAS,locked an site _ Were the septic tank manholes uncovered,opened,and the interim of the tank inspected for the condition of��e or t'material of constimbon,dimensions,&76 of liquid,depth of sludge and depth of scum Was the facility owner(and ocuprits if different from ice of owner)provided with inforneati on on the proper .sewage-dispoW-SySoems- The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no — wasting information.For example,a plan at the Board of Health. _v— Determined in the field(if any of the failure criteria related to Part C is at issue( �)) approximatioa of distance is unacceptable)[310 CMR 15.302 3 I ` Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION'FORM PART C SYSTEM INFORMATION Property Address: 10 b 0 N T N L4 v� Gi v2— �j � Owner. /;( 4, o� Date of Inspection: oZ FLOW CONDIMNS RESEDENTML Number of bedrooms(design): Number of looms(actual): DESIGN flow based.on:310 CMR 15.203(for example. 110 gpd.x#.of bedrooms):�p Number of current resides: / Does residence have a garbage grinder(yes or no):�O Is laundry on a separate sewage system(yes or no):Z!!L2 [if yes separate inspection required] Laundry system inspected(yes or no):,I' Seasonal use:(yes or no):�0 Water meter readings,if available(last 2 years usage(gpd)): Sump lump(yes or no):LfiO Last date of occupancy: /-",c ti COM[ERCIAL/INDUSTRULL Type of establishment: Design flow(based on 310 CMR 15.203): Spd 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 e: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: ,i— Was system pumped as part of the inspection(yes or no): �gfV If yes,volume pumped:_pllons—How was quantity pumped determined? Reason for pumping: TYPE SYSTEM c tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool —ftivy _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) _Tigbt tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: l`7 7 e?ol-I Were sewage odors detected when arriving at the site(yes or no): Page 7 of 11 OFFICIAL INSPECTION FORM—NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address• 669 v, q✓y� �j6 C, K Oa-b 3 rS Owner: /'/Nndoc l✓ Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: A Materials of construction cast iron --46 PAC_ot#er(explain): Distance from private water supply well or suction hue: Comments(on condition of joints;venti"dence of leakage,etc.): SEPTIC TA NK-._�.on site plan) l Depth below grace: j Material of contraction /_/concMe_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by.a Certificate of Compliaie(yes or no):—(attach a copy of certificate) / Dinxugenr s - . Distancefrm4opofshidge to bottom of outlet tee or baffle: ,�� •� Scum thickness:.Loss / '/ Distance from top of scum.to tog of outlet tee or baffle: Distance from bottom of scum to bottom outlet tee or baffle:2 How were dimensions determined: o/ 'Wa c%1-1 Comments(on pumping recommendations,inlet and outlet or baffle condition,structural integrity;liquid levels ashelated to outlet im�eevidence o�7e,.etc.): �� H 40 h , O►4 Ot✓� /✓1 p on 4- GREASE TRAF�fZlote on site plan) Depth below grade:_ Material of construction:_concrete metal_fiberglass_potYethYlene_odor (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(an pumping recommendations,inlet and outlet.tee or baffle condition,structural.integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE`SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(cone mu4 /� Property Address: G 6 /� 4&'vy.^? at,• 717,4 Owner. 111164 p C Date of Inspection: ca TIGHT or HOLDING TANK!G-.*"(ank must be pumped at time of i spection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Cart: Ikons 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: 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.): PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.). f Page 9 of l t OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE,DISPOSAL Sy.STLM.INSPEMON,FORM SYSTEM WFORMATION(contimwo �/� © Owner. / % U o Date of Inspecda+r 0�' .SOIL AMRP'[M SVSYM(SAS):, (lade 4w siw Pam,eumatioa nat. If SAS not located why, . c/�eaching � /` � r �1� leaching. :. leabing ics, : leachimg ,leachingfieW munberkogOL , : overflow cesspool,number; e system Typeo'nam of technology: Comments(emote condition of sod,signs of hydraulic failure,level ofponding,damp soil,condition of vegetation, D CESSPOQI Se L'OmVool mews be pumped as part of inspectian)(iocate on site plan) Number and oe: Depth-top•of liquidto islet invert: Depth of sdxb Wyer Depth of seem layw_ Dimes of cesspool: Materials of constructim Indication o€gumdwater inflow(yes or.no): Comments(n(ft of scl;signs of hy&aww fdwm kvd of pondieg,condition of vegetation,etc.): PRIVY:&"an site plan) Materials Off Dime Depth of sow Cow(notcmdtioa cfsoil,signs.of 4draWk hHure,level.Gfpow condition of epta etc.): Page 10 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(cow Property Address: O / �' T✓�,,� cr v Owner: //��✓ O 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 wi 100 feet.Locate where public water supply enters the building c i Al' -de a 121 a G 9�- 3,5 �y Page 11 of I1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(contimied) Property Address: Owner: AM"P or, Date of Inspection: —c� SITE EXAM Slope Surface water Check cellar Shallow wells i Estimated depth to ground water feet To Please indicate(check)all methods used to determine the highgmund 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 loot Board of Health-explam Checked with local excavators,installers-(attach documentation) A=essed USGS database-explain: You musUescnIx how you wb ed the 'gh groan$water elev lil n G1C ,� A C q G Ciro 1ti2 d Wa 0 tvI 1 , D�OO .O p p 0 /O �IV d 6 ,0 Q I( O0 0 .0 � co0 2il,G ro✓► ��� C12-`y C-iC 'I I , TOWN OF BARNSTABLE BOARD OF HEALTH 2 ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date ✓ Time: In Out Owner Tenant Address l 0 ��I��Q(� k Address 49 6 b PIA Compliance Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities 6. Heating Facilities 7. Lighting and Electrical Facilities 8. Ventilation _..__-.... 9. Installation and Maintenance of Facilities 5jg0V( qLhq tAA r1,Q0k 10. Curtailment of Service PD-T R)rVe I IVNitjG, _-- 11. Space and Use - 12. Exits C-0Rue 6 AS OP- 3/ZJ.?-- 13. Installation and Maintenance of Structural Elements ar. 14. Insects and Rodents . ` 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal 17.Temporary Housing A) I s � ( 160 f(0 = 13S p z 18. Driveway Width tx 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; Removal of Occupants;(Demolition Number of Bedrooms �l Number of Vehicles ax) Number of Persons Allowed (max) _ Person(s) Interviewed Inspector If;Public Building such as Store or Hotel/Motel specify here f TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II:MINIMUM STANDARDS FOR HUMAN HABITATION �� s Date 11D Time: In V�Out D 5 Owner /71�V � Tenant ��''JQ1614 b��T -I�de, Address � � � S-0-0 Address (AU P14vhv) 17 Compliance Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities lot V*5 4. Water Supply 5. Hot Water Facilities �" l v - 6. Heating Facilities 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal 17.Temporary Housing 7S j f 1j 18. Driveway Width 19. Number of Tenants Observed 1 a�� �® 1�� ~P PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms 99 Number of Vehic to d (ma Number of Persons Allowed (max) J Person(s) Interviewed J Inspector If Public Building such as Store or Hotel/Motel specify here / _ TOWN OF BARNSTABLE Approved: !MLD Cent: BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date k ' is, \C of Time: In 2 :Zo Out Z'3 r Owner Dw1.1 Ata(--)12V.W S Tenant Address Address A,V T- Compliance Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply 2 5. Hot Water Facilities ceA S v JO 6. Heating Facilities 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal e-%v A. 17. Temporary Housing 18. Driveway Width 19. Number of Tenants Observed A/ - PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms Number of Vehicles Allowed (max) Jr' Number of Persons Allowed (max) Person(s) Interviewed Inspector �. . If Public Building such as Store or Hotel/Motel specify here TOWN OF BARNSTABLE LGSCATION 1 (03 ��'�et tM ��'e. SEWAGE # I J'`/L5 VILLAGE � gok ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO.Cark�m.3 —LI^I7 _a`b3., SEPTIC.TANK CAPACITY LEACHING FACILITY: (type) (size)'74' 3 4 - . . ��S'�-tswe-. NO. OF BEDROOMS 3 �' \ �:.�-�r-a�o�-S . BUILDER OR OWNERV - �e-�-� V@ tai l PERMIT DATE: eG ",+� `I.S COMPLIANCE DATE: 7 /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) N 0 Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 t of leaching facili ) Feet Furnished by �9,►,J � Z 91 ra �7 Z � A � C . ` . TOWN OF BARNSTABLE 1 WEATION C3 R)T&jArv-\ A J e- SEWAGE # VILLAGE Cz7Cs i`- ASSESSOR'S MAP 6z LOT INSTALLER'S NAME St PHONE NO. SEPTIC TANK CAPACITY k LEACHING FACILITY:(type) k 0G6 6 (size) NO. OF BEDROOMS 2, PRIVATE WELL O PUBLIC WATE BUILDER OR OWNER Ly- tvyl ( y- u X DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIA,�I=QEN!B7.D* �Y�s NNo c P �� ���