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HomeMy WebLinkAbout0172 RALYN ROAD - Health 172 !Ra[yn load _ cotu it P f ---- 022 054 i I Commonwealth of Massachusetts Title .5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary 'Assessments Property Address Cr C f� / er �e ON ner Ow ner's Name information Is Ceti required for every page. City/rown State Zip Code Date of Inspe6tlon 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. Ynng out forms:When A. General Information u fin the comput on the computer, y only mothe ve tab your 1• Inspector: key to Y cursor-do not use the return Name of Inspector _ key , �► Company Name Company Address //'' //�/ Od 6 q �Gi S ✓''I City/Town State Zip Code a� go Telephone Nu License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported.below is true, accurate and-complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CM 15.000). The system: d= Passes ❑ Conditionally Passes ❑ Fail,-I ZIE ❑ Needs Further Evaluation by the Local Approving Authority Pa 3 �1 ral Inspec is Signature Date e The ystem inspector shall submit a copy of this inspection report to the Approving Authority (B�rd 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. / � One•3!13 TiUe5Officlet InspectiVS.blurlace Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System orm -Not for Voluntary Assessments /* i V, PCi- Property Address / , �. Y'f �2�er C74- Cw ner Cw ner's Name 1 Information Is O / y � 0a,6�`j required for every / / -k ;� A-Ll � page. City/Town State Zip Code Date of nspe ion B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) :71 m asses: 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: (Ilse S ca 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): ins'3/13 T109501BciallnapectionForm Suburface Sewage Disposal System-Page 2of17 Commonwealth of Massachusetts Title 5 Official Inspection Form t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments / AlV, �C) Property Address ON ner Ow ner's Name 11 information Is co �-N IL Ad required for every page. City/Town State Zip Code Date of spec' n 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 mannerwhich will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5iny,W$ T109 5 Official Ins pac lion F orm Subsurface Sewage Disposal System•Page 3of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage/Disposal System Form -Not for Voluntary Assessments / e) 4yq Property Address ON ner ON ner's Name information is N �� requiredforevery ✓ / -_ page. Citylrown State Zip Code Date of Inspect on B. Certification (cont.) 2. System will fall 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 ❑ Ere"" Backup of sewage into facility or system component due to overloaded or / clogged SAS or cesspool ❑ L�,,f/ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow Ifts•W 3 Title 6 Official Ins pection F orm Subsurface Sewage Disposal System•Page 4 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage {^Disposal System Form -Not for Voluntary Assessments r / / I l • "v Property Address ON ner O v ner's Name � information is / d required for every C ^ page. CitylTown State Zip Code Date of irfspeeVon 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: . ElLJ 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. ❑ CB' Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ L7 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 collform bacteria Indicates absent and the presence of ammonia nitrogen and nitrate nitrogen Is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ The system ifljl_* I have determined that one or more of the above failure criteria exist as described in 310 CM 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑- the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— IWPA)or a mapped Zone 11 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. t5ns.3M 3 Title WfAciel Ins pectlan F am Subsuface Sewage Disposal System•Page 5 of 17 r - Commonwealth of Massachusetts ARM Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °- I j— Qg4 ,, 11-2d Property Address Ow ner ON ner's Name Information is O f A* A-// required for every o` page. City/Town State Zip Code Date of nape tion 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 ❑ ere any of the system components pumped out in the previous two weeks? ❑ Has the system received normal flows in the previous two week period? ❑ Have large volumes of water been introduced to the system recently or as part of 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): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): t5ns 3f13 Tille501flelel Inspection Form Subsurfaee Sewage Disposal System•Page 6of17 l. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '/ 9C�_ Property Address / ► /�� Pit/ O.v ner ON ner's Name information is co _I _ �U required for every page. Otyfrown State Zip Code Date of In ect' D. System Information Description: / /o / //� I(C Number of current residents: 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 years usage(gpd)): Detail: Sump pump? ❑ Yes o Last date of occupancy: Date Commercla III ndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM R 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: larr•3l13 Title 5OfflclelIreM ctionFom[SubsufaceSe^alaDI osel System•Page7of17 A Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9d, nx Property Address P— ON ner ON ner's Name information is co required for every page. Cfty/Town State Zip Code Date of In pecti 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 es volume pumped:yes, p p gallons How was quantity pumped determined? Reason for pumping: Type of S "m: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Altemative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner)and a copy of latest inspection of the VA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): kqn,3113 Me 50fticial Inspection F am Subsurface Sewage Disposal System-Page$of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments J / �pZ �/ (QC_-J Property Address Orr ner Ory ner's Name information is CO 4 required for every J J page. Citylfown State Zip Code Date of Inspect on D. System Information (cont.) Approximate age of all components, date installed(if known) and source of in ation: 30/Were sewage odors detected when arriving at the site? ❑ Yes to Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet �enal�hstruction: 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 certificates) ❑ Yes ❑ No Dimensions: `lam Sludge depth: Wns-3M3 Title5Olflelal Ins pectionForm:Subsurfaee Sewage Disposal System-Page 9of17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments A�i A, v, i�d Property Address �✓ ,,� Cw ner Av ner's Name / Information is Co4(.t 1 required for everyA� page. CityfTown State Zip Code Date of I pecti D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle l / How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): PLA / 4,, AV Z__ea l-s. 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 On8.W3 TitleSOfflclet InspectionFam:Subsuface Sewage Disposal System-Page 10 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Foam -Not for Voluntary Assessments r a / �J— /I Property Address Oar ner Cw ner's Name Information is (70 4(4 1 � � �6� required for every page. City/Town State Zip Code Date of In ctio 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 tens•3113 Title 5Officid Inspeciian F orm Subsurface Sewage Disposal System•Page 11 of 17 ,i l Commonwealth of Massachusetts Title 5 Official Inspection Form V Subsurface Sewage Disposal System Form -Not for Voluntary Assessments / 9(z AQ Property Address Ow ner Ow ner's Name U/ �,� / Information is Co ,� '� ( � A required for every page Cityrrown State Zip Code Date of In pectiq D. System Information (cont.) Distribution Box (if present must be opened) (locate on site planj. f/e,ri7 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.): My So/ 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: t5ins•3/13 TItle50fflclal InspecOon Form Subsurface SewageDispossl System•page 12 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form u Subsurtace Sewage Disposal System IF -Not for Voluntary Assessments Property Address C w ner Cw ner's Name Information is (104(414 .0d 63- /3-//lf required for ever State Zip Code Date of In pecti page. Cityrrown System Information cont. D. S st (cont.) Y Type: U'a _�-oD CA a N Z4,1f � �! l > 't p✓� ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): i pki-e G '1 C/ S ✓IS � a� � � —� G/ Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3M3 Matti Official Inspection Form Subsurface Sewage Disposal System•Page 13 of 17 L_ r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �d �� /43 0 /L) Property Address ON ner ON ner's Name information is Co4� .� �,,(� required for every / ybr J page. Citylrown State Zip Code Date of Ins ectio D. System Information (corn.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Ons•3113 TItle50fAciallns tlanFormSubsurfeceSe pec Sewage Disposal System Page 14 of 17 l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Fo] -Not for Voluntary Assessments 19 oh, Pd Property Address V— ON nor information is Ory ner s Name o, ��'i ,J D���� A//v required forevery (�` -� /`t page. Qy/Town State Zip Code Date of Fip- tion D. System Information (cont.) Sketch Of Se age Disposal System: Provide a view of the sewage disposal system, including ties to at least t permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate wher ublic water supply enters the building. Check one of the boxes below: -hand-sketch in the area below ❑ drawing attached separately lal � 3o� Co (p/- 5 G ao /� - ay t51ns•3113 Tile 5Official InspeclionFam:Subsurface Sewage Disposal System•Page 15 d 17 L I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments l �J— /�a1 /C, 0 C Property Address ON ner Cw ner's Name information is Co 4LI , A//4 O�?G 3 j�' j required for every page. City/Town State Zip Code Date ofinspection D. System Information (cont.) a� Site Exam: o �a ❑ Check Slope f 1f ❑ Surface water ❑ Check cellar ❑ Shallow wells / Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: pate ❑_ /Observed site(abutting property/observation hole within 150 feet of SAS) L�' 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: AV L0W111C4w.jC-1 Before filing this Inspection Report, please see Report Completeness Checklist on next page. One-3/13 Title 5 Of fldal Inspection F art[Subsurfece Sewage Disposal System-Page 16 of 17 L Commonwealth of Massachusetts ub Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I �� az�3 A V Property Address Cw ner Cw ner's Name q information is required for every page. Citylrown State Zip Code We of Ins echo E. Report Completeness Checklist Inspection Summary: A, B, C, D, or E checked Inspection Summary D(System Failure Criteria Applicable to All Systems) completed �l Sy em Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t51ns•3113 Tille501ficlal inspection Form Subsurface Sewage Disposal System•Page 17 of 17 J ------------------- Jy` YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years]. A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L. - it does not give you permission to operate.) You must.first obtain the necessary signatures on this fon-n at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. DATE: MOV R S,a 013 Fill in please: ® APPLICANT'S YOUR NAME/S: ejj /1 [ t' o. BUSINESS YOUR HOME ADDRESS: 141 IZcr V, R 026,3 TELEPHONE # Home Telephone Number NAME OF CORPORATION: NAME OF NEW BUSINESS e 00.fi"Ais Cv. TYPE OF BUSINESS r d 01.s IS THIS A HOME OCCUPATION? ZC YES NO / ��L ADDRESS OF BUSINESS I i f iYIA MAP PARCEL NUMBER [Assessing) When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. Authorized Signature* COMMENTS: 2. BOARD OF HEALTH This individual has,�eeR(V-r, of the permit requirements that pertain to this type of business. Authorized Signature COMMENTS: 3. CONSUMER AFFAIRS [LICENSING'AUTHORITY] This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: i * TOWN OF BARNSTABLE BOARD OF HEALTH -7 ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date Time: In Out Owner( AT1 /A KIC-5rL-9 Tenant c ►�1 �� 1�L- Address - !; sloe utj Address bi CDq- Compliance Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities 6. Heating Facilities O V La 1 o rJ 5 7. Lighting and Electrical Facilities �V1116, F 5 - 0ti 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 1 36 17.Temporary Housing IV t 18. Driveway Width 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms 3 Number of Vehicles Allowed (max) Number of Persons Allowed (max) Person(s) Interviewed d W/o Inspector If Public Building such as Store or Hotel/Motel specify here M TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION r Date to Time: in Out Owner Tenant Address Cy� � Address Complia a Remarks or Regulation# Yes YNO Recommendations 2. Kitchen Facilities Appmved: '7 3. Bathroom Facilities s 4. Water Supply I 5. Hot Water Facilities 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 f irL 17. Temporary Housing 18. Driveway Width 19. Number of Tenants Observed PART II ( ` 37. Placarding of Condemned Dwelling; ' Removal of Occupants; Demolition Number of Bedrooms 3 Number of Vehicles Mlowed (max) Number of Persons Allowed (max) 5 -- ZA 7- ( 1 Person(s) Interviewed Inspector If Public Building such as Store or Hotel/Motel specify here <L-� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 172 Ralyn Road Property Address Richard Norenberg - Owner Owner's Name information is Cotuit MA 02635 October 13, 2007 required for 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. Important: A. General Information When filling out C� forms to the /^NO TY computer,use 1. Inspector: `./ L.� only the tab key /��� 1 to move your David D. Flaherty Jr., R.S. y cursor-do not Name of Inspector use the return key. Flaherty Environmental Services Company Name t P.O. Box 81 r _. Company Address ` ' Yarmouth Port MA 02675f--`� ' rein City/Town/Town State �j�i Zip Code ty --7 _ S14713 i 508 362-1657 Telephone Number License Number r srn G, 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 ❑&"si er Evaluation by the Local Approving Authority October 15, 2007 Ins 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. t5insP Yn 172 Ral Rd Cotuit.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M y 172 Ralyn Road Property Address Richard Norenberg Owner Owner's Name information is required for Cotuit MA 02635 October 13, 2007 every 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: 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 completio f the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in t ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 ye s old*or the septic tank(whether metal or not) is structurally unsound, exhibits substan 'al infiltration or exfiltration or tank failure is imminent. System will pass inspection if the e ' ting tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass ' spection if it is structurally sound, not leaking and if a Certificate of Compliance indicating tha he tank is less than 20 years old is available. ND Explain: ❑ Observation f sewage backup or break out or high static water level in the distribution box due to broken obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass ins ction if(with approval of Board of Health): ❑ broken pipe(s)are replaced obstruction is removed t5insp 172 Ralyn Rd Cotuit.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,ay' 172 Ralyn Road Property Address Richard Norenberg Owner Owner's Name information is required for Cotuit MA 02635 October 13, 2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ 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 Bo rd of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required y the Board of Health: ❑ Conditions exist which require urther evaluation by the Board of Health in order to determine if . the system is failing to prote public health, safety or the environment. 1. System will pass unle s Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the sy em is not functioning in a manner which will protect public health, safety and the enviro ent: ❑ Cesspool or rivy is within 50 feet of a surface water ❑ Cesspool r privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System wil fail unless the Board of Health (and Public Water Supplier, if any) determines at the system is functioning in a manner that protects the public health, safety and nvironment: ❑ T e system has a septic tank and soil absorption system (SAS)and the SAS is within 100 fee 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. t5insp 172 Ralyn Rd Cotuit.doc•06/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 172 Ralyn Road Property Address Richard Norenberg Owner Owner's Name information is required for Cotuit MA 02635 October 13, 2007 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health ( nt.): ❑ The system has a septic tank and SAS and the SA s 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 nalysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the pr sence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no ther 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 El ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow ❑ ® 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. t5insp 172 Ralyn Rd Cotuit.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ��M ,•�''r 172 Ralyn Road Property Address Richard Norenberg Owner Owner's Name information is required for Cotuit MA 02635 October 13 2007 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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 CM 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 s tem the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate ei er"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the syst is within 400 feet of a surface drinking water supply ❑ ❑ the stem is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ t system is located in a nitrogen sensitive area(Interim Wellhead Protection rea—IWPA)or a mapped Zone II of a public water supply well If you have answer d "yes"to any question in Section E the system is considered a significant threat, or answered"ye in Section D above the large system has failed. The owner or operator of any large system consid ed a significant threat under Section E or failed under Section D shall upgrade the system in acc rdance with 310 CMR 15.304.The system owner should contact the appropriate regional off• a of the Department. t5insp 172 Ralyn Rd Cotuit.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 172 Ralyn Road Property Address Richard Norenberg Owner Owner's Name information is required for Cotuit MA 02635 October 13 2007 every page. CityrFown 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. ® 11 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)] t5insp 172 Ralyn Rd Cotuit.doc 08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 172 Ralyn Road Property Address Richard Norenberg Owner Owner's Name information is required for Cotuit MA 02635 October 13, 2007 every page. City/Town State Zip Code Date of Inspection 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 Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: present 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/person sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding t k present? ❑ Yes ❑ No Non-sanitary waste 'scharged to the Title 5 system? . ❑ Yes ❑ No Water meter rea rugs, if available: Last date of ccupancy/user Date Other( scribe): t5insp 172 Ralyn Rd Cotuit.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 172 Ralyn Road Property Address Richard Norenberg Owner Owner's Name information is required for Cotuit MA 02635 October 13, 2007 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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) ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 3/5/1998 BBOH Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp 172 Ralyn Rd Cotuit.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 172 Ralyn Road Property Address Richard Norenberg Owner Owner's Name information is required for Cotuit MA 02635 October 13, 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 2.5 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): joints good, venting through house adequate, no evidence of leakage Septic Tank(locate on site plan): Depth below grade: 2 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: 3„ Distance from top of sludge to bottom of outlet tee or baffle 31" Scum thickness 9.1 Distance from top.of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? sludge judge, tape measure t5insp 172 Ralyn Rd Cotuit.doc•08/06 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 172 Ralyn Road Property Address Richard Norenberg Owner Owner's Name requiratifor Cotuit MA 02635 October 13 2007 required for every page. City/Town 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.): inlet &outlet tees ok, tank seems structurally sound, liquid level appropriate, no evidence of leakage Grease Trap (locate on site plan): Depth below grade: eet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):. Dimensions: Scum thickness Distance from top of scum to top of tlet tee or baffle Distance from bottom of scum t ottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping commendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related outlet invert, evidence of leakage, etc.): Ti/hHg Tank(tank must be pumped at time of inspection) (locate on site plan): Deade: Mtruction: ❑ ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): . t5insp 172 Ralyn Rd Cotuit.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 172 Ralyn Road Property Address Richard Norenberg Owner Owner's Name information is required for Cotuit MA 02635 October 13, 2007 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumpi Date Comments (c dition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert n/a 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.): dbox seems level, no evidence of solids carryover, no evidence of leakage Pump Chamber(locate o site plan): Pumps in working or er: ❑ Yes ❑ No Alarms in worki order. El Yes ❑ No t5insp 172 Ralyn Rd Cotuit.doc•08/ Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 172 Ralyn Road Property Address Richard Norenberg Owner Owner's Name information is required for Cotuit MA 02635 October 13 2007 every page. CitylTown State Zip Code Date of Inspection D. System Information(cont.) 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: Type: ❑ leaching pits number: ® leaching chambers number: (2)w/4'stone ❑ 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.): soil dry, no signs of hydraulic failure, no ponding, SAS located mostly under driveway(H-20 chambers) t5insp 172 Ralyn Rd Cotuit.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts 4 r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 172 Ralyn Road Property Address Richard Norenberg Owner Owner's Name information is required for Cotuit MA 02635 October 13 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection)(locate on site an): 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 Comments (note condition of soil, signs of draulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note co dition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)-. t5ins 172 Ral Rd Cotuit.doc•08/06 p yn Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 172 Ral n Road Property Address Richard Norenber Owner Owner's Name information is Couit MA 02635 October 13, 2007 required for State Zip Code Date of Inspection every page. Cityrrown D. System Information (cont.) 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. TT c r 8 Z- ZqZ57 c `3 - lq 1 II t5insp 172 Ralyn Rd Cotuit.doc•08106 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 172 Ralyn Road Property Address Richard Norenberg Owner Owner's Name information is required for Cotuit MA 02635 October 13, 2007 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 ground water: >12 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: You must describe how you established the high ground water elevation: hand augered to 12', no groundwater encountered t5insp 172 Ralyn Rd Cotuit.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 Town of Barnstable OF THE Tp� Regulatory Services B,, , ABLE Thomas F. Geiler,Director y Mass. �► 0 Public Health .Division ArFD��A Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition,by receiving this report the Town of Barnstable Health Division does not automaticallya the number of bed rove pp rooms listed within this report. The actual number of bedrooms approved at.a particular property would-be listed on the "Disposal Work Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. zazl+ 6A COMMONWE4 H OF MASSACHUSETTS = EXECUTIVE QFFICE bV E �NMENTA.L AFFAIRS �EPAIi.TMTVTO ;N ?:II (�I;1�MENTAL PROTECTION AP ®22 - " 0�4 �f I Y TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION RE��19/E� Property Address: / /! A SEP 0 8 2004 Owner's Name: Owner's Address: TOWN OF BARNSTABLE I HEALTH DEPT; Date of Inspectio Name of Inspec .'pleas print) `, o Company Name. Mailing Address: ` Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address an that the information reported below is true,accurate and complete as of the time of the inspection. The inspection s performed based on my training and experience in the proper function and maintenance of on site sewage disp sal systems. I.am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.00 ). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Appro ing Authority 'ills Inspector's Signature: D e: The system inspector shall submit a copy of this inspection report to.the Appr . 'ng Authority(Boa lealth or DEP)within 30 days of completing this inspection. If the system'is a shared system or as a esign flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office ofthe 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 ]tow the system will perform in the future under the same or,different conditions of use. '� Title 5 Inspection Form 6/15/2000 page 1 fi. Page 2 of 11 OFFICIAL-INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _ Owner: 71 Date of Inspection: Inspection.Summarf.. Check A,B,C,D or E/ALWAYS complete all of Section D A. `S stem Passes: 1� I have not found an information which indicates that an of the failure criteria described in 10 CMR Y y3 15:303 or in 310:CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B: System Conditionally Passes:. One.or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank.is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructedpipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system.required pumping more than'4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health):. broken pipe(s)are replaced obstruction is removed ND explain: 2 ' 1 Page 3 of l'I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: .Owner. Date of Inspection: Law- 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 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 tributan,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 **T his system passes if the well water analysis, perfonned at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A,copy of the analysis must be attached to this form. 3. Other: Page 4 of I 1 OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _ t;l 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 f/ Static liquid level in.the distribution.box above outlet invert due to an overloaded or clogged SAS or cesspool _ Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times um ed p P . _ 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. V Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50.feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well-with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a.DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the-well is.free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen.is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should.contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large systetn the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes" or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the.system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II.of a public.water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section L 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYS7('I+M INSPECTION FORM PART B CHECKLIST Property Address: `7 Owner: Date of Inspection: Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes o Pumping.information.was provided by the owner, occupant, or Board of Health t/1'-were,any of the system components pumped out in the previous two weeks ? _ X,�f 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) j/ _ Was the facility.or dwelling inspected for signs of sewage back up ? C/ Was the site inspected for signs of breakout? V 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 constniction, dimensions, depth of liquid, depth of sludge and depth of scum? _V_ 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, V Determined 'to the field(if and of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 MR 15.302(3)(b)] 5 . Page 6 of 11 OFFICIAL INSPECTION-FORM-=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address; Owner: Date of Inspection /� FLOW CONDITIONS RESIDENTIAL 1,5 Number of bedrooms(design):2 Number of bedrooms(actual): DESIGN flow based on 310.CvIR 15.203 (for example: 11.0 gpd x #of bedrooms):3aD Number of current residents: Does residence:have a garbage grinder(yes or no): Is laundry on a separate sewage system (yes or no if yes separate'inspection required] Laundry system inspect e (yes or no):� Seasonal use: (yes or no): Water meter readings, if a (able(last 2 years usage (gpd)):Pz z 1Q� ` " Sump pump (yes or no): r_.'... Last date of occupancy: `c�,� Uad twzo�w y COMMERCIAL/INDUSTRIAL_,' Type of establishment: Desi-n flow.(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc,): „ Grease trap present(yes or no): Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: 14A 11-71,1 Was system pumped as part of th inspectio (yes or r :_ If yes, volume pumped; gallons--I-Iow was quantity ptiniped determined'? M Reason for pumping:. V OF SYSTEM ptic 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 technolo t 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): p •oxiimate age of all components, date installed(if known)and source of information: re sewage odors-detected when arriving at the site(yes or no): 19 Page 7ofII OFFICIAL INSPIJCTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: Y BUILDING SEWER(locate on site plan)0& Depth below grade: Materials of construction:_cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK: (locate on site plan 1, Depth below grade: Material of construction: ncrete_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: .0— Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: —p-- Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or ffle'. How were dimensions determined: Comments(on pumping recommenda ons, i et and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evide c of leakage, et t ,.../ GREASE TRAP locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Page 8 of 11 OFFICIAL:INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property ress: ate Owner: Date of Inspection. L2-iQ a-, TIGHT or HOLDING TANK -(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_^polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: Gallons/day Alarm present(yes or no): y Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX:Zof present must be opened)(locate on site plan) Depth of liquid level above outlet invert��� ?2n Comments(note if box is level and distribution to outl s equal, any evidence of solids carryover,any evidence of Me into 0 out of box, ); a `, C. [J i! iA PUMP CHAMB!�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.): 8 Page 9 of 1 1 OFFICIAL INSPECTION F ORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: HC? Owner: 417-ft A. Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why: X g pits,number:g 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. CESSPOOL�(cesspool must be pumped as part of inspect ion)(]ocate 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 constriction: Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVVf�locate on site plan) Materials of constriction: Dimensions: Depth of solids: - Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 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: O Owner: Date of InspectionIT 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. ' t-L jt�, On ��� � ! it t bw4o, b�q `.J 11 r-J�d(bbed 10 Page l l of l l OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water Z 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: �Necked with local excavators, installers-(attach documentation) ccessed USGS database-explain: You must describe how you established the high ground water elevation: J77t rp�n} z e Permit Nu�,{,�.� tuber: Date: } f "t Completed b {may/MR F.�s @c a ? C. c lI NI D-i!A7 ER LEVEL r EL COMPUTATION _ - .:..... Site Location: � Lot No. - :���•� wner: f� � .Address: yyob ���� �I / � y` Address: .c7; 1y k : F .::-.<--::•Contractor: q' a. Notes: �1�5 A1111 r'm6i i •i STEP 1 Measure depth to water table J �/ tonearest 1/10.ft .............................................................:................ .Date tie,;-5 1Z��7 r ;:''r:::' month/day/Year r °�,. STEP 2 Using Water-Level Rance Zone and Index Well Map locate site and determine: �A A .`,.� ,Appropriate inde;:weli.. �!!t/ OWater-)evel range zoine ...................................................... STEP 3 Using monthly report ''Current ,!hater Resources Conditions" determine current depth to �L water level for index; well ........................... month/year STEP 4 Using Table of Water-level Adjustments for inde>c well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 2B) determine water-level adjustment .......................................................................................... STEP 5 Estimate depth to high water by subtracting the water- t level adjustment (STEP 4) (_ from measured depth to water i; : level at site (STEP 1) ............................................................................................................. IV Figure 13.--P,eproducidle computation form. I 15 �m ' I i V� COMMONWEALTH'OF MASSACHUSETTS s EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS �l DEPARTMENT OF ENVIRONMENTAL PROTECTION .. t; ONE W';t�P1�E�t STREET. BOSTON. MA 02108 617-292-5500 1 WILLIAM F.WELD TRUDY COXE Governor Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION Property Address: 1 72 Ral Rd, Cotuit . Address of Owner: Florence Curtis Date of Inspection:S_ �-- 9 F (If different) Name of Inspector: Wm E Robinson Sr I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: Wm E Robinson Septic Service Mailing Address: PO Box 1 089 r Cent-ervi 1 1 P r MA 02632 Telephone Numbera 5 0 8 ; 7 7 s—R 7 7 F CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that orted below is true, accurate and complete as of the time of inspection. The inspection was performed based on my fining and experience in roper function and maintenance of on-site sewage disposal systems. The system: llPasses �Prt — Conditionally Passes . 1 t5 Needs Further Evalu ion 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 within thirty (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-Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: 6] S STEM 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 repa'Vv,4 approved by the Board of Health, will pass. Indic to yes, no, or not determined (Y, N,.orjNb). Describe basis of determination in all instances. If"not determined", explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web: http:Nwww.magnet.state.ma.usldep �'j Printed on Recycled Paper SUBS gR,.ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 172 Ralyn Rd, COtuit Owner: Curtis Date of Inspection: ,3—c—� B] STEM CONDITIONALLY PASSES (continued) _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or.obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] F RTHER EVALUATION IS REQUIRED,Q•Y.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 the public health, safety and the environment. 1.1), SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER 'WHIC,,H'YYILl,'PROTECT THE PUBLIC HEALTH AND 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. SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid). 3 OTHER L (reviaad 0 /25/9 ) Pa 4 7 e 2 of 10 g SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A lz CERTIFICATION (continued) {'1, Property Address: 172 Ralyn Rd,f Cotuit Owner: Curtis Date of Inspection: y C'.r g 25 D] SYSTEM FAILS: YouruYou must indicate ei; ,er "Yes" or "No" as to each of the following: st in I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Ye No Backup of sewage into facility or system component due to an 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 1/2 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 Soil Absorbttc0'System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool u'i 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] RGE SYSTEM FAILS: Yo must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: .The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of 4-tributary to a surface drinking water supply _ the system is located in a nit'r:'ogen sensitive area (Interim Wellhead Protection Area- IWPA) or a mapped Zone II of a public water supply well) ': The o ner.or operator of any such system_ shall bring the system and facility into full compliance with the groundwater treatment program requi ements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) • Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 172 Ralyn -Rd, Cotuit Owner: Curtis Date of Inspection: 3-C - c/ Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes/ No Y — Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. V As built plans have been obt ir,"red and examined. Note if they are not available with N/A. — The facility or dwelling inspected for signs of sewage back-up. — The system does not receive non-sanitary or industrial waste flow. — The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)] (revised 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 172 Ralyn Rd, COtult Owner: Cu t i Date of Inspection: 3" FLOW CONDITIONS RESIDENTIAL: Design flow �.p.d./bedroom for S.A.S. Number of bedrooms:3 Number of current residents: Garbage grinder (yes or no):_&,_0 Laundry connected to system (yes or no):AL5 Seasonal use (yes or no): Water meter readings, if available (last two (2) feair usage (gpd): 1996 — 55, 000g Sump Pump (yes or no):it d 1997 — 45, 000g Last date of occupancy:J�"C— 0079 ERCIAUINDUSTRIAL: Type o'establishment: Design flow: gallons/day Grease trap present: (yes or no)_ Industr al Waste Holding Tank present: (yes or no)_ Non-s itary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last ate of occupancy: OTH : (Describe) Last d of occupancy: GENERAL INFORMATION PUMPING RECORDS ar)d source of information: System pumped as part of inspection:,�yr's o� no) t.D If yes, volume pumped. a o---d g llbns Reason for pumping: TYPE Q SYSTEM t/ 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) I/A Technology etc. Copy of up to°date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no)ICJ (revised 04/25/97) .7iiD Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 172 Ralyn Rd, COtuit Owner: Curtis Date of Inspection: BUILDING SEWER: (Locate on site plan) ' Depth below gr de: Material of co struction: _cast iron _40 PVC _other (explain) Distance om private water supply well or suction line Diamet r Com ents: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:_ (locate on bite plan) G j Depth below grade: l Material of construction: "concrete _metal _Fiberglass _Polyethylene —Other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) ` J, Dimensions: K a Sludge depth: o , Distance from top of sludge to bottom of outlet tee or baffle:_ Scum thickness: a ` i Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of Qgij) f'tee or baffle: el How dimensions were determined: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, cl pth of liquid level in relation to outlet invert, structural inteGgrity, evidence of leaka e, etc.) ate. '7-A�" `f G GREAS TRAP: (locate n site plan) Depth low grade: Materia of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dime sions: Scu thickness: Dist ce from top of scum to top of outlet tee or baffle: Distan a from bottom of scum to bottom of outlet tee or baffle: Date of ast pumping: Comme s: (recom endation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integri , evidence of leakage, etc.) (revised 04/25/97) Page 6 of 10 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 172 Ralyn Rd, Cotuit Owner: Curtis Date of Inspection: TI HT HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (loca onOR site plan) Depth low grade: Materi I of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dime sions: Capa ity: gallons Desi n flow: gallons/day Alar level: Alarm in working order _Yes; _ No Dat of previous pumping: Com ents. (condi ion of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) at PUMP C AMBER:_ ` ' (locate on site plan) Pumps in orking order: (Yes or No) Alarms i working order (Yes or No) Comme s: (note c dition of pump chamber, condition of pumps and appurtenances, etc.) (revised 04/25/97) Page 7 of 10 ,!, i{ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 172 Ralyn Rd, COtuit Owner: Cu rjt 1 S Date of Inspection: 3— W— ; SOIL ABSORPTION SYSTEM (SAS): !� (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ s ' leaching chambers, number: leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, c ndition of vegetation, etc.) :!� dG 6 9g CES POOLS: _ (loca on site plan) Numb r and configuration: Depth- p of liquid to inlet invert: Depth f solids layer: Depth f scum layer: Dimens ons of cesspool: Materia s of construction: Indicat n of groundwater: irflow (cesspool must be pumpeda as Patt of inspection) d Comm ts: (note co dition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate o site plan) Material of construction: Dimensions: Depth of_ lids _ Comments. (note co ndi ion of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 172 Ralyn Rd, COtuit Owner: urtis Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: j include ties to at least two permanenp-references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 6r J 'yv p I V\ `r V is J 4 fM�4 3 ' �e � O 1 � /114�'t.-j ,34-9 y (revised 04/25/97) 4- / ���3 Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 172 Ralyn Rd,, •'Cotuit Owner: Curtis Date of Inspection: 3—�-5 g ,k Depth to Groundwater );L- Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use-USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) (revised 04/25/97) Page 10 of 10 t l -b No. Fee 5 0 . 0 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for Mitpoaf *pgtem Conotruction Permit Application for a Permit to Construct( )Repair(cx)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 1 7 2 R a 1 y n Road Owner's Name,Address and Tel.No. 4 2 8—4 01 6 Assessor'sMap/Parcel Cotuit Florence Curtis 172 Ralyn Rd 6 2 ;? — 45� Cotuit MA 02635 Installer's Name,Address,and Tel.No. 7 7 5—$ 7 6 Designer's Name,Address and Tel.No. W E Robinson Septic Sry PO Box 1085, Centerville, MA 02632 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder(no) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil sand Nature of Repairs or Alterations(Answer when applicable) T i t l e 5 L P a c h i n cg c on s i s tr)f a D—Box and two H-20 precast leach chambers ( stonepacked) Date last inspected: Agreement: The..,undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Bo4d of Health. c _g Signed Date Application Approved by - Date Application Disapproved for the following reasons r Permit No. Date Issued x TOWN OF s4AMWRWR L.QCATI ON: 1 7 2 �A�,�i�n /�►rrt� a 1."]; CS S :.VILLAGE: ell LOT # : / PERMIT i y ` INSTALLER'S NAME: IVJ,/ �'D/��i� -01V 77.E-g774 L I'N:S:TALLER'S PHONE # : 7 7 'LEACHING FACILITY: (type .S�G'�.[ ' e) NO.. . OF BEDROOMS: BUILDER OR OWNER' F Pf1tMIT DATE: --- _- COMPLIANCE DATE: /;c% DRAW DIAGRAM ON BACK `� - F 01, �,. 0 � Ji" No. / Fee$5 0.0 0 1 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓ Yes PUBLIC HEALTH DIVISION- TOWN OF BARNSTABLES MASSACHUSETTS 01pprication for Zigpogat *pztem Construction Permit Application fora Permit to Construct( )Repair(XX)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot.No. 172 Ra l yn Road Owner's Name,Address and Tel.No. 4 2 8—4 01 6 Assessor'sIvfap%Parcel � �lhtt Florence Curtisa 172 -Ralyn Rd Cotuit MA 02635 Installer's Name,Address,and Tel.No: 7 7 5—8 76 Designer's Name,Address and Tel.No. 1 W1,1X,-1Robinson Septic Sry 'P0'`Box 1089, Centerville, MA 02632 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage,Grinder(no) Other Type of Building 3NdA--Pef?o_s', --Showers( ) Cafeteria( ) r. Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. .Description of,Soil sand ,i Nature of Repairs or Alterations(Answer when applicable) Title 5 Leaching consi gti ct of a D-Box and two H-20 precast leach chambers (stonepacked) 7- Date last inspected: Agreement: -. 1te�undersigned agrees to ensure the construction and maintenance of the afore described, -site sewage disposal system 'Ardccordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- ` u cate of Compliance has been issued,by this o �of.Heatl- r% /� �!�, ���}- Signed l c.'tS f� f" .. date'`, z Application Approved by Date - •- A plication Disapproved for the following reasons ~� Permit l'`o ' " .Date'�Issued t5 ��- -= �-------------=-J'----------------- ~`� `` THE COMMONWEALTH OF MASSACHUSETTS Curtis �.. F ���BARNSTABLE, MASSACHUSETTS �,,. `•�, �., certif irate of Compliance f ,THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired�KX•)Upgraded( ) Abandoned )by r� rat 172 Ral n Roa'd Cotuit -- has been constructed in accordance s, with the provisions of Title 5 and the for Disposal System Construction Permit=N � dated Installer / W E Robinson Sept Sry Designer The iss dnce of this permit sh not a con trued as a guarantee that the system will function as designed. Inspectors. ,f No. % �/ Fee $5 0•`. 00 r THE COMMONWEALTH OF MASSACHUSETTS �x PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Curtin Mi5pozal 0potemn Conotrurtion Permit Permission is•hereby granted to Construct( )Repair�Cx)lUpgrade( )Abandon System located at 172 Ratyn Road Cotuit, MA Installer: W E Robinson Septic Sry _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 conditio s" Provided:Construction must be completed within three years of the date of this rmit. + � Date: —^ J�1 Approve t R.. 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 ENGINEERED PLANS) I, William E. Robinson, Sr. ,hereby certify that the application for disposal works construction permit signed by me dated -3` /,/- 7 , concerning the property located at 172 Ralyn Road Cotuit, NIA, meets all of the following criteria- * There are no wetlands within 100 feet of the proposed leaching facility. * There are no private wells within 150 feet of the proposed septic system. * There is no increase in flow and/or change in use proposed. t * There are no variances requested or needed. * If the proposed leaching facility will be located with 250 feet of any wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the makimum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S. map) B)Observed Groundwater Table Evaluation(according to Health Division well map) SIGNED: /�, ,E- •• v,� DATE Ll—� LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 20-1998 (Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted). it I� sow.. YL� �GS 1 No.......... COMMISSION .............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH- ............ . ... ........OF............6 .... ....... .................. Appliration for Uhnpaaal Works (filimtrurtiott Vantit Applica 'on is hereby made ' a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: 1 -------------- ..I..... .... ..........�. =..x ......... ....................... 6................................................. �� i Location•�ddres or Lot No. 1/ " !�` •� -cx:�_...... r.. 14- Owner Add re G a --------....7.0.h�.......rJ_�..�:� —:1------------------------------- -------�'.�=mow.��..r��-----; .._----------------------....----------- Installer Address U Type of Building, S Size Lot..... fe Dwelling X No. of Bedrooms..... .................................Expansion Attic ( ) Garbage Grinder '_l Other—Type of Building No. of persons____________________________ Showers — Cafeteria P' Other fixtures --_--.---__•___________ _ _ W Design Flow............ ........../.�.�.....J�allons per person per day. Total daily flow----------- . ...............gallons. W Septic Tank 1�Liquid capacity��lY(`gallons Length................ Width---------------- Diameter................ Depth.............. -- x Disposal Trench—, o..................... Width-------------------- Total Length----------- _._.... Total leaching area............. ---sq. ft. Seepage Pit No______ ___________ Diameter... _e!__v�... Depth below inlet___--_--��........_. Total leaching area..X.4 ........sq. ft. Z Other Distribution box ( ) Dosing tank (/ ) '~ Percolation Test Results Performed by.- .��1��> _. Date 1 --�/--•---•--- aTest Pit No. I................minutes per inch Depth of Test Pit-___......._..____._ Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to grou d water------------------------ O Description of Soil ` ..... .. . .......... x W ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•-------...... UNature of Repairs or Alterations—Answer when applicable.--__......................................................................:.................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T T . y g g p y of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be issued by the board of health. 40. IL Signe _- --_... ... ....................... ..........................-.... Date Application Approved By...... --....j---g- .. --_....._ ........._. - - -1 l•-------- Application Disapproved for the following reasons:.........:.............................................: ......................•---_..__Date•--••--------- --....•--••-•----••----••••...---•-----•--•-•••••---••••-----•-•-••-•••-.....--•••-•-•----•---•-•---•-----•-----•••--•-----------------------------•---------------------------------------------------- Date PermitNo......................................................... Issued....................................................... Date N(......... .�.?.... j�...-•-•_...... THE COMMONWEALTH OF MASSACHUSETTS BOAR® Ol. ( ;:T E-�w;� :�; ...._.. .Y.. ..'.....OF......... �' ...... ............................... Appliration for Uiipniial Works Tnnitrnrtiun famit Application is hereby made for a Permit to Corfstr uct ( ) or Repair ( ) an Individual Sewage Disposal System at: ...... .................. ........•••-...._._.. .... .......................................................... L cation-Address r Lot No. • -.�.��.Gs ..�2 ................................... ...f.S� �S.J. ...... . ......................__ `I" , Owne Address n " Installer Address 411 Type of"BuildiygS �y_Fes, Size Lot___� ��___-__Sq. feet a Dwelling/—No. of Bgdrooms...........�`�.:.........................Expansion Attic ( ) Garbage Grinder } Other.—Type of ;$u, '19.. ........................... No. of persons............................ Showers ( ) — Cafeteria ( ) Othe res a w Design Flo, ____.__: ------=------�°- - ' .,tg,�ons per person per day.'Total daily flow--_-----_�..�., W Septic Tang' ' Liquid capaci/;v> l&ns Length................ Width................ Diameter................ Depth........,....... . Disposal Trench—INo.t__________________ Wi t �__.� . Total Length........ ___.____ Total leaching area.......... .....sq. ft. x .I, -•-- Seepage Pit No..................... Diameter ._.._._....._..._. Depth below inlet..... Total leaching area.G_v.. ....sq. ft. Z Other Distribution box ( ) Dosing. ank I Percolation Test Results Performed b ___ Jlc ._�,_. _ 45! k ______________ Date."_:�................................ aTest Pit No. I.................minutes per inch Depth of Test Pit.................... Depth to ground water.--__---___-_-____------ fi, Test Pit No.. 2.................minutes per inch-: Depth of Test Pit.................... Depth to gro nd water........................ - --------- O Description of Soil "'" '� ? _ .."... �„•-- J7Ol ---- P t�1�4 x w -------------------------------------------------------------------------------- -------------------------------------------------=--•••••••--•••--••------••-----•-••-•-•-••......--•••••-••-•••---•... U Nature of Repairs or Alterations Answer when applicable-----_------------------------------------------................................................ ----------------------------------------------------------------•-----------------.........._.....----------------------------------•---------------------------------------------------------•---•••. Agreement The undersigned agrees to install the afo'redescribed Individual Sewage Disposal System in accordance with the provisions of-T T.L.: y g g p y 5 of the State Sanitary. Code= The undersigned further agrees not to lace the system in operation until a.Certificate of Compliance has b n issued by the board of health. Sign . ................................ .' ,�,,y Dat Application Approved BY �:�.. •-• --_•-•• -..... ._.... '�/ -------------------------------- Date� Application Disapproved for the following easons: -......------•---••--•--•-------•--------------------- ------------•------------------- ---••---- - Date PermitNo................................ ---------------------- Issued....................................................... Date 3 N. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH '....�` ......oF..... ........................................................... Totifiratr of Tomplianrr T S I TO C . IFY at,the Individual Sewage Disposal System constructed ) or Repaired ( ) by ............. I st -t j�' a C Ilec � •,•• has been installed in accordance with the provisions of ` o The State Sanitary Co e as descr bed in the h. application for Disposal Works Construction Permit N ---- __________�1..3........... dated___.__ ..�.�.f�..Q`--/--_•-•--•-. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE.CONSTRIIED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTIOW SATISFACTORY. DATE........................... ................................... Inspector.........=- -------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD 9f HEALTH Vz 7—o�................OF......... ,'2 ..................... ..�....�.: . '" FEE ............. iurks 'tnn rrnti Perim' sio hereby nted_... to Const ct or p 'vi al age o0Sem at No.. ••-•- -• •-• - ... .-t ------------- -- a •.•- Street as shown on the application for Disposal Works Construction Per it N _______ Dated..�'...._.�'.�`I_�.......... .. Board of Health DATE FORM 1255 HOBBS & WARREN. INC., PUBLISHERS - h TOWN OF LOCATION: 1 72 �r A��/i✓ >�j� ----/G►�a 0 3.—. 6 T! , VILLAGE: ` O LOT # : PERMIT # : - - INSTALLER'S NAME: �J't7? �- J"'p/�i iV �'©�/ 7S'= ►�7 INSTALLER' S PHONE # : LEACHING FACILITY: (type' � 4A '3e) NO. OF BEDROOMS: 3 BUILDER OR OWNER: J _ PERMIT DATE: COMPLIANCE DATE: DRAW DIAGRAM ON BACK a L,nCATION SEWAGE PERMIT NO. 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