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HomeMy WebLinkAbout0071 TARAGON CIRCLE - Health !71 Tarttgpp Circle C:otuit - --- A= 041.-01'A05 I1 Commonwealth of Massachusetts )01 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments C v� 71 Tarragon Circle Property Address Michelle Gemborys Owner Owner's Name information is it MA 02635 t ou 05/16/20 required for every C � page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information filling out forms on the computer, use only the tab Mathieu Rebello key to move your Name of Inspector cursor-do not N/A use the return Company Name key. Norse Co .. � Company Address South Dennis MA 02660 Citylrown State Zip Code 774-722-0271 SI-14140 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 05/16/20 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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.doc•rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 i Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 71 Tarragon Circle Property Address Michelle Gemborys Owner Owner's Name information is required for every Cotuit MA 02635 05/16/20 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 1 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: 2) 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. s *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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Tarragon Circle Property Address Michelle Gemborys Owner Owner's Name information is Cotuit MA 02635 05/16/20 required for every i page. CityrTown State Zip Code Date of Inspection C. Inspection Summary (cont.) . 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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 :below (Explain ) ❑ 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): 3) 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. a. 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: t5insp.doc-rev.7/W018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 9 ' c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 71 Tarragon Circle Property Address Michelle Gemborys Owner Owner's Name information is required for every Cotuit MA 02635 05/16/20 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Tarragon Circle Property Address Michelle Gemborys Owner Owner's Name information is required for every Cotuit MA 02635 05/16/20 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 Y2 day flow_ ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. 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 t5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 71 Tarragon Circle Property Address Michelle Gemborys Owner Owner's Name information is required for every Cotuit MA 02635 05/16/20 page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts UTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 71 Tarragon Circle Property Address Michelle Gemborys Owner Owner's Name information is required for every Cotuit MA 02635 05/16/20 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 gpd Description: Number of current residents: 1-2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d N/A irrigation 9 ( Y 9 (gpd)): system Detail: j Sump pump? ❑ Yes ® No current Last date of occupancy: Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 71 Tarragon Circle Property Address - Michelle Gemborys Owner Owner's Name information is required for every Cotuit MA 02635 05/16/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: N/A Design flow(based on 310 CMR 15.203): N/AGallons per day(gpd) Basis of design flow seats/ ersons/s .ft. etc. : N/A Grease trap present? ❑ Yes ® No Water treatment unit present? ❑ Yes ® No If yes, discharges to: N/A Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: N/A Last date of occupancy/use: N/A Date Other(describe below): NIA 3. Pumping Records: Source of information: last pumped 2 years ago Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.cloc•rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 71 Tarragon Circle Property Address Michelle Gemborys Owner Owner's Name information is Cotuit MA 02635 05/16/20 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 1991 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 1' Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments(on condition of joints, venting, evidence of leakage, etc.): joints tight,proper venting, no evidence of leakage. i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 71 Tarragon Circle Property Address Michelle Gemborys Owner Owner's Name information is required for every Cotuit MA 02635 05/16/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 6"feet Material of,construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallon tank Sludge depth: 411 Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? sludge judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tee's in place in working condition, no signs of leakage or over loading. Liquid level is equal with outlet invert. Tank did not need to be pumped. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts uTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Tarragon Circle Property Address Michelle Gemborys Owner Owner's Name information is required for every Cotuit MA 02635 05/16/20 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: N/A feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): N/A Dimensions: N/A Scum thickness N/A Distance from top scum of to tor of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle N/A Date of last pumping: N/A Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): N/A 8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: N/A Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): N/A Dimensions: N/A Capacity: N/A gallons Design Flow: N/A gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 71 Tarragon Circle Property Address Michelle Gemborys Owner Owner's Name information is required for every Cotuit MA 02635 05/16/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: N/A Alarm in working order: ❑ Yes ❑ No Date of last pumping: N/A Date .Comments(condition of alarm and float switches, etc.): N/A "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): box is level and solid with no sign of carryover or leaking in or out of box. t5insp.doc-rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 71 Tarragon Circle Property Address Michelle Gemborys Owner Owner's Name information is required for every Cotuit MA 02635 05/16/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. 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.): N/A *If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: N/A Type: ® leaching pits number: 2-6'x6' ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form , I.- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 71 Tarragon Circle Property Address Michelle Gemborys Owner Owner's Name information is required for every Cotuit MA 02635 05/16/20 page. Cityrrown state Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): soil found clean and dry.No signs of hydraulic failure at time of inspection.6"of ponding at bottom of leach pit#1 no high stain lines. Leach pit#2 inspected with camera an found to be in same condition as pit#1 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A Depth—top of liquid to inlet invert N/A Depth of solids layer N/A Depth of scum layer N/A Dimensions of cesspool N/A Materials of construction N/A Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 71 Tarragon Circle Property Address Michelle Gemborys Owner Owner's Name info . d for is Cotuit MA 02635 05/16/20 require every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: N/A Dimensions N/A Depth of solids N/A Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A �R t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 71 Tarragon Circle ,U'Vif Property Address Michelle Gemborys Owner Owner's Name information is required for every Cotuit MA 02635 05/16/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® 'drawing attached separately t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts -- r Title 5 Official Inspection Farm` Subsurface Sewage,Disposal System;Form - Not for Voluntaey•:Assessments 71 Tarragon Circle Property Address Dean Fraser Owner Owner's Name- information is required for Cotuit. .. . MAC_ 02635 March-25. 2010 every page; Cityrrown State Zip Code Date of inspection t D. System information (cant:) : 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 buil.di:ng, 3. 61 / 50 ater Service r Tarragon Circle �W Commonwealth of Massach,usefts Title 5 Official Inspection Form SubsurfaceSewage,Disposal System Form - Not for Voluntary Assessments 71 Tarragon;Circle Property Address Dean Fraser Owner Owner's Name information is Cotuit MA 02635 March 25, 2010 required for —_____... .....___.._.....__ .__. every page. Cityrrow n State Zip Code Date of Inspection - D. System Information (cost.) 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 E Yes E] No Comments(,note.condition of soil, signs of hydraulic failure,level of ponding,,condition of vegetation, etc.): Privy (locate onsite.plan); Materials.of`construction: Dimensions Depth of solids. -- Comments(note condition of soil, signs of hydraulic:failure, level of ponding, condition of vegetation, etc.): 10.75 Fraser.doc 081M Titla 5 Otiicol Inspection.Fdan:.Subsurface Sewage Disposal Syslem Page 13 0l 15 Commonwealth of Massachusetts Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Tarragon Circle Property Address Michelle Gemborys Owner Owner's Name information is required for every Cotuit MA 02635 05/16/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 2 fe eett 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: town groundwater contour map shows water at el. 35 and topo map shows property at el. 50 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/28J2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Tarragon Circle Property Address Michelle Gemborys Owner Owner's Name information is required for every Cotuit MA 02635 05/16/20 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2,.3, or 5 completed as appropriate 4 (Failure Criteria)and 6(Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Commonwealth of Massachusetts Title 5 Official Inspection. Form Subsurface Sewage Disposal System form - Not for-Voluntary Assessments 71 Tarragon Circle Property Address Dean Fraser Owner Owner's Name information is required for Cotuit. MA 02635 March 25, 2010 _ 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:When filling out A. General Information forms on the I computer,use 1. Inspector: (/I only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. Company Name r� 189 Cammett Road Company Address Marstons Mills MA 02648 Cityrrown State Zip Code 508-428-1779 SI 12855 Telephone Number _ License Number BXertification 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 ❑,4E Is r a : .r , ❑ Needs Further Evaluation by the Local Approving Authority cp March 25, 2010 In ector's Signa re Date The system inspector shall submit a copy of this inspection report to the App�oving Authority Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared�syst�ln or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit thte 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. 10-75 Fraser.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Y V Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 Tarragon Circle Property Address Dean Fraser Owner Owner's Name information is required for Cotuit MA 02635 March 25, 2010 every page. Cityfrown State Zip.Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Tank is not in need of pumping at this time, leaching pits are functioning properly. 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. 1 ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed 10-75 Fraser.doc•08106 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 71 Tarragon Circle Property Address Dean Fraser Owner Owner's Name information is required for Cotuit MA 02635 March 25, 2010 every page. Cityrrown 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 Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: 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 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. 10-75 Fraser.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 Tarragon Circle Property Address Dean Fraser Owner Owner's Name information is required for Cotuit MA 02635 March 25, 2010 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (coot.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or."No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than_day flow ❑ ® 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. 10-75 Fraser.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts e. Title 5 Offici al Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 Tarragon Circle Property Address Dean Fraser Owner Owner's Name information is required for Cotuit MA 02635 March 25, 2010 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.] 0 ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ 0 the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 10.75 Fraser.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 71 Tarragon Circle Property Address Dean Fraser Owner Owner's Name information is required for Cotuit MA 02635 March 25, 2010 every page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CMR 15.302(5)] 10-75 Fraser.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 71 Tarragon Circle Property Address Dean Fraser Owner Owner's Name information is required for Cotuit MA 02635 March 25, 2010 every page. CityrTown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 3 DESIGN flow based on 310 CM 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 4 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 N/AWater meter readings, if available last 2 ears usage d system. irrigation 9 ( Y g (gpd)): system. Sump pump? ❑ Yes ® No Last date of occupancy: CurrentlyOccupied Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Dace Other(describe): 10-75 Fraser.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 Tarragon Circle Property Address Dean Fraser Owner Owner's Name information is required for Cotuit MA 02635 March 25, 2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Tank pumped 12/8/09 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: 1991 Were sewage odors detected when arriving at the site? ❑ Yes ® No 10-75 Fraser.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 M 71 Tarragon Circle Property Address Dean Fraser Owner Owner's Name information is required for Cotuit MA 02635 March 25, 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 1 feet Material of construction: ❑cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 6 feet Material of construction: ®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------- ---------------------------------------------- Dimensions: 10.5' long x 5.8'wide- 1500 gal. Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 2 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 12 How were dimensions determined? Measured 10-75 Fraser.doc-08106 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 71 Tarragon Circle Property Address Dean Fraser Owner Owner's Name information is required for Cotuit MA 02635 March 25, 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Liquid level was found at bottom of outlet invert, tees were intact and clear. Tank is not in need of pumping at this time. 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 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): 10-75 Fraser.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments '( 71 Tarragon Circle Property Address Dean Fraser Owner Owner's Name information is required for Cotuit MA 02635 March 25, 2010 every page. City/Town 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 pumping: Date Comments(condition 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 0" ' Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No solids or high stains present, liquid level at bottom of both outlet pipes. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 10-75 Fraser.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 71 Tarragon Circle Property Address Dean Fraser Owner Owner's Name information is required for Cotuit MA 02635 March 25, 2010 every page. Citylrown 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: Two 6x6 pits. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp,soil, condition of vegetation, etc.): Leaching pit#1 had 16-18" of standing water with no high stains. Leaching pit#2 was not opened. 10-75 Fraser.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 S4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Tarragon Circle Property Address Dean Fraser Owner Owner's Name information is required for Cotuit MA 02635 March 25, 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top.of liquid to inlet invent 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 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.): 10-75 Fraser.doc•08106 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 71 Tarragon Circle Property Address Dean Fraser Owner ------_._...--------------------------------..-..----------- ---------- Owner's Name information is Cotuit MA 02635 March 25, 2010 required for _ _ every page. Cityrrown State Zip Code Date of Inspection 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. 44 16 45 319 f i , / / , , , . / , f • , / 61 , \ , , , , , .. , , , ♦ , , , , / , r , r r r / / f / / / , / / 50 Water ervice Tarragon Circle • • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 Tarragon Circle Property Address Dean Fraser Owner Owner's Name information is required for Cotuit MA 02635 March 25,2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to ground water: 20+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-,explain: USGS topo map and;.own GIS. You must describe how you established the high ground water elevation: Town groundwater contour map shows water at el. 35 and topo map shows property at el. 50. 10-75 Fraser.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 i `.: COMMONWEALTH OF MASSAwHUSETTS r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS Y ti DEPARTMENT OF.ENVIRONMENTAL PROTECTION a>1 /a cz TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: Owner's Name. Owner's Address:-7/ Date of Inspection.. Z4 zyrs/6:' Name of Inspe please print )) Company Nab Mailing Address: �ftDO y Telephone Number: 7 co _r CERTIFICATION STATEMENT -- > I certify that I have personally inspected the sewage disposal system at this address and that the i formatigrepoffed below is true, accurate and complete as of the time of the inspection. The inspection was perform d based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DE.P approved system inspector pursuant.to Section 15.340 of Title 5(310 CMR 15.000). The system: S/ Passes Conditionally Passes E eeds Further Evaluation by the Local Approving Authority � Fit Inspector's Signature: Date: 6 ,0(_ —The system inspector shall submit a cop i 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 shar-.d system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,'and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address'how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/20.00 page 1 Page 2 of 11 OFFICIAL INSPECTIO FORM—NOT FOR VOL•'UNTARY,ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Addre$s:� Own " Date of Inspectionl,,,. ,f LC Joo-�, Inspection Summary: Check A,B,.C,D or E/ALWAYS complete all of Section D A. yytem Passes: tr I.haa e no pound any 1afonnation which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria.not evaluated are indicated.below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional_Pass":section;need to be replaced or repaired. The system,upon completion of the replacement or repair;as approved by the Board of Health,vyill,pass. rat 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 20years 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 complyir_g septic tank:as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation,of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass.inspection if(with approval of Board of Health): broken pipe(s)are.replaced obstruction is removed distribution box is leveled or replaced. ND explain: The system required pumping.more tha'n'4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is.removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: b Owne v Date of Inspection 772 -v- C. Further Evaluation is Required by the Board.of Health: Conditions exist which require further evaluation by the.Board o 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'1'5 303(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 l 2. System will fail unless the BOird 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 surface water supply or tributart;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 thp-n 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform .bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,.provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 n Page 4 of I 1 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PAR.[ A. CERTIFICATION(continued) Property Address. Ow Date of Inspections e "� D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes N9 } t/ Backup.of sewage into facility or system component due to overloaded or.clogged SAS or cesspool Discharge or ondin of effluent to the u� surface of the round or surface waters duet an overloaded P g g o o rloaded or clogged SAS or cesspool Static liquid level in the dis-ribution box above outlet invert due to an overloaded or.clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than'/2 day flow 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 j water supply. �,0 . Any portion of a cesspool.or privy is within a Zone 1 of a.pub`�ic 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 tha.t.no other failure criteria are triggered. A copy of the analysis.must be attached to this form.] l�® (Yes/No)The system fails. I have determined-that one or more of the above failure criteria.exist as described in 310 CMR 15.3)3,therefore the system fails. The system owner should contact the Board of I-Lealth 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 10i000 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 cf 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 syste-ii 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 r f the Department. A i Page 5 of 1 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION'FORM PART B CHECKLIST Property Address: 7 Z _d Owner: Date of Inspection. Check if the following have been done: You must indicate"yes"or"no",as to each of the followina: Yes No Pumping,information was provided by the owner,occupant,x 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 ? 1/ Have large'volumes of water been introduced to the system r=ently or as part of this inspection ? V _ Were as built plans ofthe system obtained and examined?(Ifthey 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 ? - V A Were all system components, excluding the SAS, located on site Were the septic tank manholes uncovered, opened, and the irterior of the tank inspected for,the condition of the baffles or tees,material of construct-ion, 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)u'n the site has been determined based on: Yes no l/ Existing information. For'?:ample,a plan atthe Board of Health. 1, Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 C1vIR 15.302(3)(,())] ,i 5 Page of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART`C i SYSTEM INFORMATION Property Address: Owne Date of Inspecti665• �-/ ao-05— RESIDENT IA � „ 1 ,L FLOW CONDITIONS Number of bedrooms(.design): Number of bedrooms(actual): DESIGN flow based on 310 CM 15.20 (fqr example: 11.0 gpd x#of bedrooms): Number of current residents: �, � Does residence have.a garbage grinder(yes or no)A/0 Is laundry on a separate sewage system ry s or no):Z.[if yes separate inspection required] Laundry system inspected(y s.or no):Z Seasonal use: (Yes or no),: 1 � Water meter readings, if av ilable(last 2 years usage(gpd)): l�*✓�� TO Uri Sump pump(yes or no)� ,U Last date of occupancy: {�• ✓''-��'` � COMMERCIAL/INDUSTRIAL , 0 Type of establishment: Design flow(based on 310 CMR 15.20 3): gpd Basis of design flow(seats/persons/sgft;2tc.): 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 Was system pumped as part of the i speCtion(yes(6r no): If yes, volume pumped: gallons—How was quantitypumped determined? Reason for pumping: TYP F SYSTEM eptic tank, distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes, atiach 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 i 5 Other(describe)` - Approximate age of components,date ;nst, lied(if own) d source of information: 67 � f Were sewage,odors detected when arriving at the site(yes or no) 6 Page 7 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2 .4 Owner: _ Date of Inspection. .BUILDING SEWER(locate on site plan) 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.): x SEPTIC TANK: (locate on site plan) Depth below grade: _ Material of construction: . oncrete 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) �x r Dimensions: �(g,,� Sludge depth: /<I ., 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 bottorrli of outlet tee or�baffie�,:How were dimensions.determine Comments (on pumping recomm nn to et and ouor ba fle condition, structural integrity, liquid levels s related to outlet invert,e idence of leakage, etc. Zia' lde_4): w 0461 Val V GREASE TRA J/(locate on'site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethyjene 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: a Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, Liquid levels as related to outlet invert,evidence of leakage, etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Propert Address: Owner. Date of Inspection: TIGHT or HOLDING TANK: O(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete _metal fiberglass polyethylen: other(explain):. Dimensions: Capacity: gallors Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): ii- DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outle qual, any evidence of solids carryover,any evidence of kage into or out of box,etc.): tr 0 PUMP CHAMBERy�0 (locate on s_te plan) Pumps in working order(yes or no): Alarms in working order(:yes or no): Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): I ' 9 ` f Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner r Date of Inspectio 5 ` SOIL ABSORPTI N SYSTEM (SAS): locate on site plan, excavation not required) If SAS not located explain why: Type b p eachin its number: leaching chambers,number: 1' leaching galleries; number: leaching trenches, number,len�tli leaching fields,number, dimensions: overflow cesspool,number _innovative/alternative system Type/name of technology: Comments(note condition of soil, sign�,, of hydraulic failure,level of ponding,damp soil;condition of vegetation, et &4LAJ > :r 49 CESSPOOLS:A (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 or no):'__ Comments(note condition of soil,signs of hydraulic failure, level of ponding,"conditioncof vegetation,etc:):' PRIVY (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil, sign'of hydraulic failure, level of ponding; condition of vegetation,etc.): 1. 9 i Page 10 of I 1 a' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTE,M.INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:. / / alf" owne Date of Inspection. ` SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.Locate where public water'supply enters the building. o J' 10 t� x ° ua a in s Page 11 of 11 OFFICIAL INSPECTION FORM—'NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Ow AD/I� y/I Date of Inspection: � � ;.060-S SITE EXAM Slope ' Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with.local excavators, installers-(attach documentation) ✓Accessed USGS database-explain: You must describe how you established the high ground water elevation: 17 P o rd l' !a 5 1 i 11 1 Permit Number: Date: Completed by: r HIGH SROUND-WATER LEVEL COMPUTATION Site Location: Z ����� Cl� Lot No. Owner: ,�Py/ /" Rio y/` Address: Contractor: Address:_� J ' °, j$�� STEP 1 Measure depth to wage;table to.nearest 1/10 ft. ..._....' ....... ....................................................... 'Date month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map IDcate '= site and determine: 5-':=' _ OA' Appropriate index evell.......... � t. ',t .. ............................ B Water-level range _cat O .".. _ yti,;;•i fir: STEP 3 !, `r �• .. _ --_`+� =ry`}�_i; Using monthly report current ws-': - Water Resources,Cond=ions' determine curr e.nt.depth"ro �n water level for index,,,Elie �ir.P� �d7r n tiL A. ................ month/year STEP 4 Using Table of Water- EeeF Adj ustments = :,•.' r: for index well (STEP 2+i), current depth to water level for index well (STEP 3), and water-level zone (STEP 2B) determine water-level zzjustment ............................................... STEP 5 Estimate depth to high water by subtracting the water- •`; z�r �'� ,`} level adjustment (STEP 4) _ r'rom measured depth to water level at site (STEP 1) _................. ............ ,,r ♦ l [ k Figure 3.--Reproducible computation form. �_ s 15 - T ....,.�... w,l` ,I^- -,...__.. .,..._�. ...... _.._..„............. �'; fa.._.._...._...... . �[ �5✓ _ ,6 �...,r w . i • I J i I `• TOWN OF BARNSTABLE LOCATIO't1. SSE — VILLAGE ,(2,oav` ASSESSOR'S MAP&PARCEL Iid NAME&PHONE NO. r,c l� Ci `i. L SEPTIC TANK CAPACITY SCw LEACHING FACILITY:(type) , �+ S (size) (oUv NO.OF BEDROOMS _ OWNER PERMIT DATE: CAE DATE—, -, ,c,P. S 110 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet. FURNISHED BY 6 f 44 J / , 1 / J , / > fffffff /•r` rff:,:', \ \ \ \ ♦ \ \ \ ♦ \ \ \ ♦ \ ♦ \ \ ♦ \ 4 \ a 16 . �,`�, 4 C .r] J , f 1 / 1 f19- \ \ \ \ \ \ \ \ \ \ \ \ ♦ +. \ \ \ \ ♦ \. \ \ \ 1 f f f f f ! / / f f f / 1 f / V C 1 _ 4 \ \ ♦ \ \ \ \ \ 4 \ 1 \ 4 \ 1 \ \ \ 1 \ \ \ 1 e 50 ater ervice i e TO p B ARNSTABLE — SEWAGE # V1,f LAGEo,`' I ASS SSOR'S MAP & LOT r � NAME&PHONE N — SEPTIC TANK CAPACITYZelx LEACHING FACILITY: (ty �/ (size) NO:OF BEDROOMS_.. `f BUILDER 0 1 0E � PERMITD'ATE: COMPLIANCE DATE:. Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching..facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by Feet ' d , CrA ...,r. ..._ .. _ ....�_.-...«...,......... .. .,.-,,...._.tee__ Q.... i I Pinc � i SeP ��, TetA I c cellar, J TOWN OF/B�ARNSTABLE LOCATIO 1. ,� `��f� y fl l i r. SEWAdE S r r VILLAGE 0yW`t- ASSESSOR'S MAP&PARCEL II4TrM NAME&PHONE NO. ��i- ;c.(� �cw� �I la b-l"Yl SEPTIC TANK CAPACITY ' �C3c0 LEACHING FACILITY:(type) �, Yi (size) (DUCE NO.OF BEDROOMS OWNER �7 PERMIT DATE: C01MMUME DATE'S.,$ S I I U Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY (�C� ' f J J f f I f f r f�I,I4I 4J�f f f / r • . . . . r 16 45 3 flff~f`JJ f fI fr / f ! ? ! 19 r r r r J`J r J f r J r r I J I J4f J f f ! 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OF BEDROOMS PRIVATE WELL OR LIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: '" L � DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No :DIr.DELIn1t� 1 SC1O LW Tf-NNK 46 �• FOX �+X�a �t 4 CAST �(T� i,J/:!, Z