HomeMy WebLinkAbout40-50 CAPTAIN COOK LANE - HYANNIS CONDOS 40-50 CAPT.COOK LANE, 09E
BLD.6 �
visa"&ilk
ROSANO DAVIS
9 ROCKY LANE
COHASSET MA 02025
(781)383-1234 (781)545-2800 (781)749-6178
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGK DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address 40-50 Captain Cook Lane
Building 6
Center Village,Hyannis,MA
Owner's Name Multiple Owners
Owner's Address Huntingest Property Management34
/I n
40 Industry Road—P.O.Box 340 !� f�
Marstons Mills,MA 02648
Date of Inspection 01/22/09
Name of Inspector Paul W.Davis
Company Name Rosano Davis Sanitary Pumping Inc.
Mailing Address 9 Rocky Lane
Cohasset,MA 02025
Telephone Number 781-383-1234
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,
accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the
proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section
15.340 of Title 5(310 CMR 15.000). The system:
®Passes
❑Conditionally Passes
❑Needs Further valuatio by the Local Approving Authority
❑Fails
Inspector's Signature: Date:01/30/09
The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)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 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.
LA
1
Title 5 Inspection Form 6/15/2000
ROSANO DAVIS
9 ROCKY LANE
COHASSET MA 02025
(617)383-1234 (6.17)545-2800 (617)749-6178
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION(Continued)
Property: 40-50 Captain Cook Lane/Building 6
Center Village,Hyannis,MA
Owner: Multiple Owners
Date: 01/22/09
INSPECTION SUMMARY:Check A,B,C,D or E/ALWAYS complete all of section D
A] SYSTEM PASSES:
X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 or in 310 CMR 15.3(
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.
Indicate 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 breakout 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. The system will pass inspection if(with approval of the 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
LTitlepection Form 6/15/2000
ROSANO DAVIS
9 ROCKY LANE
COHASSET MA 02025
(617)383-1234 (617)545-2800 (617)749-6178
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION(Continued)
Property:40-50 Captain Cook Lane/Building 6
Center Village,Hyannis,MA
Owner: Multiple Owners
Date: 01/22/09
C Further Evaluation is Requiredby the Board of Health:
Conditions exist which require further evaluation by the Board or Health in order to determine if the system is failing to protect the
public health,safety and the environment.
1) System will pass unless Board of Health determines in accordance with 310 CMR 15.303(I)(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 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 of more from a private water supply
well". Method use 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
Title 5 Inspection Form 6/15/2000
ROSANO DAVIS
9 ROCKY LANE
COHASSET MA 02025
(617)383-1234 (617)545-2800 (617)749-6178
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION(Continued)
Property: 40-50 Captain Cook Lane/Building 6
Center Village,Hyannis,MA
Owner: Multiple Owners
Date: 01/22/09
D System Failure Criteria applicable to all systems:
You must indicate either"Yes"or"No" to each of the following for all inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool.
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
X Liquid depth in cesspool is less than 6"below invert or available volume is than 1/2 day flow,
_ X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
_ X Any portion of the SAS,cesspool or privy is below the high groundwater elevation.
_ X Any portion of a cesspool.or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X 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. [The 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.]
NO(Yes/No)The system I have determined that one of more of the following failure criteria exist as described in 310 CMR 15.303,
fails. therefore the system fails. The system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E.Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
You must indicate either"Yes"or"No"to each of the following:
(The following criteria apply to large systems in addition to the criteria above.)
Yes No
LTitle
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 H of a
public water supply well)
4
ection Form 6/15/2000
ROSANO DAVIS
9 ROCKY LANE
COHASSET MA 02025
(617)383-1234 (617)545-2800 (617)749-6178
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION(Continued)
Property: 40-50 Captain Cook Lane/Building 6
Center Village,Hyannis,MA
Owner: Multiple Owners
Date: 01/22/09
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 with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department.
�-- This page intentionally left blank
4
5
Title 5 Inspection Form 6/15/2000
ROSANO DAVIS
9 ROCKY LANE
COHASSET MA 02025
(617)383-1234 (617)545-2800 (617)749-6178
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM"
PART B
CHECKLIST
Property: 40-50 Captain Cook Lane/Building 6
Center Village,Hyannis,MA.
Owner: Multiple Owners
Date: 01/22/09
Check if the following have been done You must indicate"yes"or"no"as to each of the following_
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health
_ X Were any of the system components pumped out in the previous two weeks?
X _ Has the system received normal flows in the prevous two week period?
_ X Have large volumes of water been introduced to the system recently or as part of this inspection?
X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out?
X _ Were the septic tank manholes were uncovered,opened,and the interior of the septic tank inspected for condition of baffles
or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum?
X _ 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 on the site has been determined based on:
Yes No
X _ Existing information.For example, Plan at.B.O.H.
X _ 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)]
6
Title 5 Inspection Form 6/15/2000
ROSANO DAVIS
9 ROCKY LANE
COHASSET MA 02025
(617)383-1234 (617)545-2800 (617)749-6178
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART C
SYSTEM INFORMATION
Property:40-50 Captain Cook Lane/Buildine 6
Center Village,Hyannis,MA
Owner: Multiple Owners j
Date: 01/22/09
FLOW CONDITIONS
RESIDENTIAL:
Number of bedrooms(design): Number of bedrooms(actual): 12 units.
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
Number of current residents: Number varies but typically 15 on average
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): No (If yes separate inspection required)
Laundry system inspected (yes or no): _
Seasonal use(yes or no): No
Water meter readings,if available(last two(2)year usage(gpd)): Water usage records were not available at time of inspection
Sump Pump(yes or no): No
Last date of occupancy: 01/22/09—Units were still occupied at time of inspection
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design 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:Property currently under regular maintenance schedule Tank was pumped 11/17/08
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: gallons-how was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool,
_ Privy
No 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)
No Tight Tank. Attach a copy of the DEP Approval
Other(describe)
Approximate age of all components,date installed(if known)and source of information: 36 years per previous inspection
Were sewage orders detected when arriving at the site(yes or no): No
7
Title 5 Inspection Form 6/15/2000
ROSANO DAVIS
9 ROCKY LANE
CORASSET MA 02025
(617)383-1234 (617)545-2800 (617)749-6178
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART C
SYSTEM INFORMATION(Continued)
Property: 40-50 Captain Cook Lane/Building 6
Center Village,Hyannis,MA
Owner: Multiple Owners
Date: 01/22/09
This page intentionally left blank
8
Title 5 Inspection Form 6/15/2000
ROSANO DAVIS
9 ROCKY LANE
! COHASSET MA 02025
(617)383-1234 (617)545-2800 (617)749-6178
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART C
SYSTEM INFORMATION(Continued)
Property: 40-50 Captain Cook Lane/Building 6
Center Village,Hyannis,MA I
Owner: Multiple Owners
Date: 01/22/09
BUILDING SEWER(locate on site plan)
Depth below grade: 42".
Material of construction: X cast iron 40 PVC other(explain) Cast iron inlet pipe.
Distance from private water supply well or suction line:No known wells in immediate area.
Comments:(on condition of joints,venting,evidence of leakage,etc.)
All piping appeared to be clean and flowing freely.No evidence of leakage
SEPTIC TANK: YES(locate on site plan)
Depth below grade: 30".
Material of construction: X concrete metal Fiberglass Polyethylene
other(explain)21000-gallon precast concrete septic tank.
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes or No):_(Attach a copy of certificate)
Dimensions:b' deep X 4' wide X 12' long.
Sludge Depth: 4_'.
Distance from top of sludge to bottom of outlet tee or baffle: Zabel filter in place.
Scum thickness: 0".
Distance from top of scum to top of outlet tee or baffle: Zabel filter in place.
Distance from bottom of scum to bottom of outlet tee or baffle: Zabel filter in place.
How dimensions were determined:Measured with a tape.
Comments:(on pumping recommendations,inlet and outlet tees or baffle condition,structural integrity,liquid levels as related to outlet
invert,evidence of leakage,etc.)
Septic tank was Pumped at time of inspection Cast iron inlet tee and A-100 Zabel filter on outlet tee in place Tank is structurally
sound and water tight and all effluent levels were at an appropriate height There are no repairs recommended at this time
GREASE TRAP:NO(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 tees or baffle condition,structural integrity;liquid levels as related to outlet
invert,evidence of leakage,etc.)
9
Title 5 Inspection Form 6/15/2000
ROSANO DAVIS
9 ROCKY LANE
COHASSET MA 02025
(617)383-1234 (617)545-2800 (617)749-6178 �
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART C
SYSTEM INFORMATION(Continued)
Property:40-50 Captain Cook Lane/Building 6
Center Village,Hyannis,MA
Owner: Multiple Owners
Date: 01/22/09
TIGHT or HOLDING TANK: NO.(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal' Fiberglass Polyethylene other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm Present(Yes or No)—
Alarm level: Alarm in working order _(Yes/No)
Date of last pumping:
Comments:(condition of alarm and float switches,etc.)
DISTRIBUTION BOX: YES.(If present,must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 011.
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 was structurally sound and water tight and providing even distribution of effluent Carryover was moderate There are no
repairs recommended at this time
PUMP CHAMBER: NO.(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.)
10
Title 5 Inspection Form 6/15/2000
ROSANO DAVIS
9 ROCKY LANE
COHASSET MA 02025
(617)383-1234 (617)545-2800 (617)749-6178
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGEDISPOSAL SYSTEM FORM
PART C
SYSTEM INFORMATION(Continued)
Property: 40-50 Captain Cook Lane/Building 6
Center Village,Hyannis MA
Owner: Multiple Owners
Date: 01/22/09
SOIL ABSORPTION SYSTEM(SAS): YES.(locate on site plan,excavation not required)
If SAS not located,explain why:
Type:
X leaching pits,number: 1 —10' deep X 6'wide leaching pit
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.):
There was no surface wetness breakout or si ns of hydraulic failure observed.Pit had 7'of effluent in it.Leaching appears to be in
good working condition.There are no repairs recommended at this time
CESSPOOLS: NO.(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,condition of vegetation,etc.)
PRIVY: NO.(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.)
11
Title 5 Inspection Form 6/15/2000
ROSANO DAVIS
9 ROCKY LANE
COHASSET MA 02025
(617)383-1234 (617)545-2800 (617)749-6178
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART C
SYSTEM INFORMATION(Continued)
Property: 40-50 Captain Cook Lane/Building 6
Center Village,Hyannis,MA
Owner: Multiple Owners
Date: 01/22/09
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system includngties to at least two permanent reference landmarks orbenchmarks. Locate all wells
within 100 feet. Locate where public water supply enters the building.
C
Io1 �� 40
x
1A/
24 '
A — D
— � ` U-
ul
12
Title 5 InsRection Form 6/15/2000
r
1
r
i
ROSANO DAVIS
9 ROCKY LANE
COHASSET MA 02025
(617)383-1234 (617)545-2800 (617)749-6178
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART C
Property: 40-50 Ca twin Cook Lane/Building
INFORMATION(Continued)
° 6
Center Villaue Hyannis MA
Owner: Multiple Owners
Date: Ol/22/09
SITE EXAM
Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to groundwater: Greater than 19 feet
Please indicate(check)all methods used to determine the high groundwater elevation:
Obtained from system design plans on record. If checked,date of design plan reviewed:
X Observed site(abutting property/observation hole within 150 feet of SAS)
X Checked with local Board of Health-explain:Previous Title 5 Inspections.
_ Check local excavators,installers-(attach documentation).
Accessed USGS database-explain:
You MUST describe how you established the High Groundwater Elevation:
DuringirtyjagLimpections the hi h oroundwater was indicated to be 19'9" below rade.Cleariv,there is se aration from the
bottom of the SAS to the hi h roundwater elevation.It was b this non-intrusive method that it was estimated that se aration exis
from the bottom of the SAS and-the hi h round water.
is
13
Title 5 Inspection Form
6/IS/2000
fl CERTIFICATE ®F ANALYSIS
" Pn;e: 1
Uarnstable County flea lth.-Laboratory
'Report Prepared For: Rcpi�-t Dafccl: I1/15/2007
Richard&Mary Farley Order No.: G0744096
44 Capfaiii Cook Lane
Centervll) MA 02632
Laboratory ID#: 074406-01 Descriptioi; Water-brinking Watcr
j
Saiitple'#: $ani)ling Location: 44 Captain Cook Ln.Centerville,MA Collected: 111712007
Collected by: R.SFa'riey Received: 111-7/2007
Routine
ITEM RTSIJLT UNITS RL MCL Method# Tested
Nitrate as Nitrogen :b9 mg/L 0.10 10 EPA 300.0 11/7/2007
Copper ND 111S/L 0.10 1.3 SM 31 I1B I1/3/2007
i
NDL _ 0.1•0 0.3- SM3111B -1.1.020e7_•:.:-- -
Sodium 18 mg/L 1.0 20 SM3111B I1/8/2007
Total Coliform ` AUs'ent P/A 0 0 SM9223 11/7/2007
Conductai1Ce';. 120 umohs/cm 2.0 EPA 120.1 11/7/2007
L i
pH 6.9 pH-units 0 SM 4500 H-B 11/7/2007
Wale sample meets the ru:ommended lmaits.ja drinking water of all the ahone tested parameters.
Approved By:
(Lab ctor)
C wR
P� f
J FYI
I
t
ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level
Superior Court House, Pf ; Box 427, Barnstable, MA 02630 Ph: 508-375-6605
ROSANO DAVIS
9 ROCKY LANE
COHASSET MA 02025 4.36 I ty at ii_
(781)383-1234 (781)545-2800 (781)749-61.78
i
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSIVIE ' ' 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address 40-50 Captain Cook Lane �7 h/
lBuilding 6 i
Center Village,Hyannis,MA n
Owner's Name Multiple Owners 7
Owner's Address Huntingest Property Management
40 Industry Road—P.O.Box 340
Marstons Mills,MA 02648
Date of Inspection Completed 1/19/06
Name of Inspector Jeffrey F.O'Connell
Company Name Rosano Davis Sanitary Pumping,Inc.
Mailing Address 9 Rocky Lane
Cohasset,MA 02025
Telephone Number 781-383-1234
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,
accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the
proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section
15.340 of Title 5(310 CMR 15.000). The system:
®Passes
❑Conditionally Passes
❑Needs Further Evaluation by the Local Approving Authority
❑Fails
Inspector's Signature: Date: 02/02/06
The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)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 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.
1
Title 5 Inspection Form 6/15/2000
f
ROSANO DAVIS
9 ROCKY LANE
COHASSET MA 02025
(617)383-1234 (617)545-2800 (617)749-6178
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION(Continued)
Property: 40-50 Captain Cook Lane/Building 6
Center Village,Hyannis,MA
Owner: Multiple Owners
Date: Completed 1/19/06
INSPECTION SUMMARY: Check A,B,C,D or E/ALWAYS complete all of section D:
AJ SYSTEM PASSES:
X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 or in 310 CMR 15.3(
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.
Indicate 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 breakout 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. The system will pass inspection if(with approval of the 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
Title 5 Inspection Form 6/15/2000
ROSANO DAVIS -
9 ROCKY LANE
COHASSET MA 02025
(61.7)383-1234 (617)545-2800 (617)749-6178
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION(Continued)
Property: 40-50 Captain Cook Lane/Building 6
Center Village,Hyannis,MA
Owner: Multiple Owners
Date: Completed 1/19/06
C Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board or Health in order to determine if the system is failing to protect the
public health,safety and 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 Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a
manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or
tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet'of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet of more from a private water supply
well". Method use to determine distance
"This system passes if the well water analysis,performed at a DEP certified Iaboratory,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
Title 5 Inspection Form 6/15/2000
ROSANO DAVIS
9 ROCKY LANE
COHASSET MA 02025
(617)383-1234 (617)545-2800 (617)749-6178
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION(Continued)
Property: 40-50 Captain Cook Lane/Building 6
Center Village,Hyannis,MA
Owner: Multiple Owners
Date: Completed 1/19/06
D System Failure Criteria applicable to all systems:
You must indicate either"Yes"or"No" to each of the following for all inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool.
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
_ X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
X Liquid depth in cesspool is less than 6"below invert or available volume is than 1/2 day flow.
_ X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
X Any portion of the SAS,cesspool or privy is below the high groundwater elevation.
X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
_ X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X 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. [The 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.]
NO(Yes/No)The system I have determined that one of more of the following failure criteria exist as described in 310 CMR 15.303,
fails. therefore the system fails. The system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E.Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
You must indicate either"Yes"or"No"to each of the following:
(The following criteria apply to large systems in addition to the criteria above.)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface 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)
4
Title 5 Inspection Form 6/15/2000
I
ROSANO DAVIS
9 ROCKY LANE
COHASSET MA 02025
(617)383-1234 (617)545-2800 (61.7)749-6178
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION(Continued)
Property: 40-50 Captain Cook Lane Building 6
Center Village,Hyannis,MA
Owner. Multiple Owners
Date: Completed 1/19/06
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 with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department.
UI�.nq ID&ge nffi9eMffGM EEy IleAu D &Mlk
5
Title 5 Inspection Form 6/15/2000
ROSANO DAVIS
9 ROCKY LANE
COHASSET MA 02025
(617)383-1234 (617)545-2800 (617)749-6178
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART B
CHECKLIST
Property: 40-50 Captain Cook Lane/Building 6
Center Village,Hyannis,MA.
Owner: Multiple Owners
Date: Completed 1/19/06
Check if the following have been done You must indicate"yes"or"no"as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks?
X _ Has the system received normal flows in the prevous two week period?
_ X Have large volumes of water been introduced to the system recently or as part of this inspection?
X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out?
X _ Were the septic tank manholes were uncovered,opened,and the interior of the septic tank inspected for condition of baffles
or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum?
_ X 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 on the site has been determined based on:
Yes No
X _ Existing information.For example, Plan at B.O.H.
X _ 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)]
6
Title 5 Inspection Form 6/15/2000
ROSANO DAVIS
9 ROCKY LANE
COHASSET MA 02025
(617)383-1234 (61.7)545-2800 (617)749-6178
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART C
SYSTEM INFORMATION
Property: 40-50 Captain Cook Lane/Building 6
Center Village,Hyannis,MA
Owner: Multiple Owners
Date: Completed 1/19/06
FLOW CONDITIONS
RESIDENTIAL:
Number of bedrooms(design): Number of bedrooms(actual): 12 units.
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
Number of current residents: Number varies but typically 15 on average.
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): No (If yes separate inspection required)
Laundry system inspected (yes or no):
Seasonal use(yes or no): No
Water meter readings, if available(last two(2)year usage(gpd)): Water usage records were not available at time of inspection.
Sump Pump(yes or no): No
Last date of occupancy: 01/19/06—Units were still occupied at time of inspection.
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design 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: Property currently under regular maintenance schedule.
Was system pumped as part of the inspection(yes or no): Yes
If yes,volume pumped: 2,000 gallons-how was quantity pumped determined?Sight glass on vacuum truck.
Reason for pumping: To determine structural integrity and water tightness of septic tank.
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
No 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)
No Tight Tank. Attach a copy of the DEP Approval
_ Other(describe)
Approximate age of all components,date installed(if known)and source of information: 36 years per previous inspection.
Were sewage orders detected when arriving at the site(yes or no): No
7
Title 5 Inspection Form 6/15/2000
f
ROSANO DAVIS
9 ROCKY LANE
COHASSET MA 02025
(61.7)383-1234 (617)545-2800 (617)749-6178
-OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART C
SYSTEM INFORMATION(Continued)
Property: 40-50 Captain Cook Lane/Building 6
Center Village,Hyannis,MA
Owner. Multiple Owners
Date: Completed 1/19/06
I
• I
9
8
Title 5 Inspection Form 6/15/2000
ROSANO DAVIS
9 ROCKY LANE
COHASSET MA 02025
(617)383-1234 (61.7)545-2800 (617)749-6178
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART C
SYSTEM INFORMATION(Continued)
Property: 40-50 Captain Cook Lane/Building 6
Center Village,Hyannis,MA
Owner: Multiple Owners
Date: Completed 1/19/06
BUILDING SEWER(locate on site plan)
Depth below grade: 42".
Material of construction: X cast iron 40 PVC other(explain) Cast iron inlet pipe.
Distance from private water supply well or suction line: No known wells in immediate area.
Comments:(on condition of joints,venting,evidence of leakage,etc.)
All piping appeared to be clean and flowing freely.No evidence of leakage.
SEPTIC TANK: YES(locate on site plan)
Depth below grade: 30".
Material of construction: X concrete metal Fiberglass Polyethylene
other(explain)2,000-2al1on precast concrete septic tank.
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes or No):_(Attach a copy of certificate)
Dimensions: 6' deep X 4'wide X 12' long.
Sludge Depth: 3".
Distance from top of sludge to bottom of outlet tee or baffle: 32".
Scum thickness: 0".
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: 14".
How dimensions were determined: Measured with a tape.
Comments:(on pumping recommendations,inlet and outlet tees or baffle condition,structural integrity,liquid levels as related to outlet
invert,evidence of leakage,etc.)
Septic tank was pumped at time of inspection.Inlet tee and outlet tees in place as required.Tank is structurally sound and water
tight and all effluent levels were at an appropriate height.There are no repairs recommended at this time.
GREASE TRAP:NO(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 tees or baffle condition,structural integrity,liquid levels as related to outlet
invert,evidence of leakage,etc.)
I
i
9
Title 5 Inspection Form 6/15/2000
ROSANO DAVIS
9 ROCKY LANE
COHASSET MA 02025
(61.7)383-1234 (617)545-2800 (6.1.7)749-6178
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART C
SYSTEM INFORMATION(Continued)
Property: 40-50 Captain Cook Lane/Building 6
Center Village,Hyannis,MA
Owner: Multiple Owners
Date: Completed 1/19/06
TIGHT or HOLDING TANK: NO.(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal Fiberglass Polyethylene other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm Present(Yes or No)_
Alarm level: Alarm in working order _(Yes/No)
Date of last pumping:
Comments:(condition of alarm and float switches,etc.)
DISTRIBUTION BOX: YES.(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 was structurally sound and water tight and providing even distribution of effluent.Carryover was moderate.There are no
repairs recommended at this time.
PUMP CHAMBER: NO.(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.)
10
Title 5 Inspection Form 6/15/2000
ROSANO DAVIS
9 ROCKY LANE
COHASSET MA 02025
(617)383-1234 (61.7)545-2800 (617)749-6178
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART C
SYSTEM INFORMATION(Continued)
Property: 40-50 Captain Cook Lane/Building 6
Center Village,Hyannis,MA
Owner: Multiple Owners
Date: Completed 1/19/06
SOIL ABSORPTION SYSTEM(SAS): YES.(locate on site plan,excavation not required)
If SAS not located,explain why:
Type:
X leaching pits,number: 1—6'X 6' leaching 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.):
There was no surface wetness,breakout or signs of hydraulic failure observed.Leaching appears to be in good working condition.
There are no repairs recommended at this time.
CESSPOOLS: NO.(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,condition of vegetation,etc.)
PRIVY: NO.(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.)
11
Title 5 Inspection Form 6/15/2000
ROSANO DAVIS
9 ROCKY LANE
COHASSET MA 02025
(61.7)383-1234 (617)545-2800 (617)749-6178
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART C ,
SYSTEM INFORMATION(Continued)
Property: 40-50 Captain Cook Lane/Building 6
Center Village,Hyannis,MA
Owner: Multiple Owners
Date: Completed 1/19/06
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.
D C 40
g
w
A C = %�
6 - C - ?ZL
A - D
Z76 '
C30
6- E -= 34 IVOI'k, scale, 8 U I,Id In, jc
12
Title 5 Inspection Form 6/15/2000
ROSANO DAVIS
9 ROCKY LANE
COHASSET MA 02025
(617)383-1234 (617)545-2800 (617)749-6178
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART C
SYSTEM INFORMATION(Continued)
Property: 40-50 Captain Cook Lane/Building 6
Center Village,Hyannis,MA
Owner: Multiple Owners
Date: Completed 1/19/06
SITE EXAM
Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to groundwater: Greater than 1.9 feet
Please indicate(check)all methods used to determine the high groundwater elevation:
_ Obtained from system design plans on record. If checked,date of design plan reviewed:
X Observed site(abutting property/observation hole within 150 feet of SAS)
X Checked with local Board of Health-explain: Previous Title 5 Inspection dated 03/29/03.
_ Check local excavators,installers-(attach documentation).
Accessed USGS database-explain:
You MUST describe how you established the High Groundwater Elevation:
During a previous inspection on 03/29/03 the high groundwater was indicated to be 19'9" below grade.Clearly there is separation
from the bottom of the SAS to the high groundwater elevation.It was by this non-intrusive method that it was estimated that
separation exists from the bottom of the SAS and the high groundwater.
13
Title 5 Inspection Form 6/15/2000
i
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
1W DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET,BOSTON MA 02108(617)292-5500
TRUDY CODE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
CERTIFICATION ��
Property Address: #40-50(Even#)Capt. Cook Lane Bld#6 Cen.Vil.Barns. tit �6 ��
owner:Huntingest Mng.Center Village Condo Assoc. �oT `
Date of Inspection:01/27/2000 rA�
y0��2 rp' o
Date of Inspection: �N� O
Name of Inspector:(Please Print) Brian T.Axon ' 7
I am a DEP_approved s stem inspector pursuant to Section 15.340 of Title 5(310 CNIR 15.000) �
Company Name Ad'�K Se c IsternsPlus
Mailing Address: fox eattc et Ma.02536
Telephone Number-
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems.The system:
X Passes
— Conditionally Passes
— Needs Further Evaluation By the Local Approving Authority
— Fails
Inspector's Signature: \ Date: 12/08/99
The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)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.
NOTES AND COMMENTS:
System has no violations of failure criteria. System functioning fine,and is maintained with pumping
scheduled maintenance program. System has 2000 gal tank w/d-box and one leaching pit w/4'of stone surround.
revised 9/2/98 Page I of 11
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: #40-50 Cant.Cook Lane Bld#6
Owner:Huntingest Mng
Date of Inspection: r12/
INSPECTION SUMMARY: A X B C or D
A. SYSTEM PASSES:
X I have not found any information which indicates that any of tfie failure conditions described in 310 CIVIR 1-6.303 exist.Any failure
criteria not evaluated are indicated below.
COMMENTS:SYstem functioning fine should be pumped for maintenance.
B. SYSTEM CONDITIONALLY
N/A One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon
completion of the replacement or repair,as approved by the Board of Health,will pass.
Indicate yes, no,of not determined(Y, N,or ND). 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 complying septic tank as
approved by the Board of Health.
— Sewage backup or breakout or high static water level observed In the distribution box Is due to broken or obstructed pips(s)
or due to a broken,settled or uneven distribution box.The system will pass inspection If(with approval of the Board of
,Health).
broken pipe(s)are replaced
obstruction is removed
distribution box Is levelled or replaced
The system required pumping-more then 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
revised 9/2/98 Page 2 of 11
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address#40-50 Capt.Cook Lane Bld.#6 Center V.
Owner Huntingest Mng.
Date of Inspection:01/27/2000
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
N/A Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health,safety and 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 THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy Is within 50 feet Of 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 AND SAFETY AND THE 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 euppiy.
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
a - <
I
revised 9/2/98 Page 3 of 1,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: #40-50 Capt.Cook Lane B1d#6 Cen.V.
Owner: Runtmest—Mng.
Date of Inspection: 01/27/2000
D. SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
N/A I have determined that one or more of the following failure conditions exist as described in 310 CMR 1 6.303.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.
Yes No
Backup of sewage into facillity or system component due to an overloadedor clogged-SAS or-cesspool.
Discharge or pending 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 Absorption System,cesspool or privy Is below the high groundwater elevation.
Any portion of a 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 I of a public well.
Any portion of a cesspool or privy Is within 60 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. LARGE SYSTEM FAILS:
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:
N/A The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant throat 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-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)
The owner or operator of any such system shall upgrade the System In accordance with 310 CMR 10.304(2).Please consult the local regional
office of the Department for further Information
revised 9/2/98 Page 4of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:#40-50 Capt.Cook Lane Bld.#6 Center V.
Owner: Huntinges Mng.
Date of Inspection: 01/27/2000
Check If the following have been done:You must Indicate either"Yes"or"No"as to each of the following:
Yes No
X Pumping Information was provided by the owner,occupant,or Board of Health.
X 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.
X As built plans have been obtained and examined.Note if they are not available with NIA.
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or Industrial waste flow.
X The site was inspected for signs of breakout.
X All system components,excluding the Soil Absorption System,have been located on the site.
X 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:Field instruments
X Existing Information.For example,Plan at B.O.H.
X 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)]
. I
X The facility owner(and occupants,if different from.owner),were provided with information on the proper maintenance of
SubSurface Disposal Systems.
revised 9/2/98 Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:#40-50 Capt.Cook Lane Bld.#Kenter
Owner: Huntingest Mng.
Date of Inspection:01/27/2000
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 1320 g,p.d./bedroom.
Number of bedrooms(design): 12 Number of bedrooms(actual): 12
Total DESIGN flow 1320
Number of current resi en s: 4
Garbage grinder(yes or no):no
Laundry(separate system)(yes or no):no If yes,separate Inspection.required
Laundry system Inspected(yes or no)
Seasonal use(yes or no),yes
Water motor readings,if available(last two year's usage(gpd): N/A
Sump Pump(yes or no):no
Last date of occupancy:now
COMMERCIAL/INDUSTRIAL
Type of establishment: N/A
Design flow: gpd f Based on 15.203)
Basis of design flow
Grease trap present:(yes or no)
Industrial Waste Holding Tank press:(yes or no)_
Non-sanitary waste discharged to the Title 5 system:(yes or no)_
Water motor readings,if available:
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
None in last three years Project Mng.
System pumped as part of inspection:(yes or no)
If yes,volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
X 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)
IIA Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date Installed (if known)and source of information, 30 years Town hall
Sewage odors detected when arriving at the site: (yes or no)no
revised 9/2/98 Page 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:#40-50 Capt.Cook Lane Bld#6 Center
Owner:Huntinge-st-Nfug.
Date of Inspection:
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of construction: cast iron _ qD pVC_ other(explain)
Distance from private water supply well or suction line
Diameter
Comments:(condition of joints,venting,evidence of leakage,-etc.)
SEPTIC TANK:
(locate on site plan)
Depth below grade:0"
Material of construc'tron: x concrete x metal — Fiberglass—Polyethylene_other(explain)
If tank is metal,list age_ Is.age confirmed-by Certificate of Compliance_(Yes/No)
Dimensions:6'x12'x6'6"
Sludge depth:
Distance from topes sludge to bottom of outlet tee or baffle: 38"
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee o, baffle, l6"
How dimensions were determined: Field Instuments
Comments:
(recommendation for pumping,condition of inlet and outlet tees or-baffles,depth of liquid level in relation to outlet invert,structural integrity
evidence of leakage,etc.) recommend trumping every 2 years.Tees liquid level m relation to tees and structural integrity all fine Ro
evidence of leakage.
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal—Fiberglass—Polyethylene_._.other(explain)
Dimensions:
Scum thickness:
Distance from topes 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:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.)
revised 9/2/98 Page 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:#40-50 Capt.Cook Lane Md.# Center village
Owner:Huntingestmr1g.
Date of Inspection:01/27/2000
TIGHT OR HOLDING TANK:N/A (Tank must be pumped prior to,or 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: gallonsiday
Alarm present
Alarm level: Alarm in working order:Yes No
Date of previous pumping: — —
Comments:
(condition of inlet tee,condition of alarm and float switches, etc.)
DISTRIBUTION BOX: X
(locate on site plan)
Depth of liquid level above outlet invert:0"
Comments:
(note-if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)Distribution equal.No evidence
of solids carry over.No evidence of leakage.
PUMP CHAMBER:No
(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.)
revised 9/2/98 Page 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:#40-50 Capt.Cook Lane Bld.#6 Center
Owner:Huntingest Mng.
Date of Inspection:0 1/27/2000
SOIL ABSORPTION SYSTEM(SAS):
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
Type:
leaching Pits,number: 1
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,damp soil,condition of vegetation,etc.)
Condition of soils and vegetation fine.No evidence of hydrolic failure
CESSPOOLS:
(locate on site
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(cesspool must be pumped as part of inspection)
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of.vagetation,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.)
revised 9/2/98 Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:#40-50 CapL Cook Lane Bld#6Center Village
Owner:Huntingest Mng.
Date of Inspection:0 1/27/2000
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within I W(Locate where public water supply comes into house)
O31 �I
�L_` Cov4,tzS —ro b2���
z3
A
yn
! LA
Lill
T
f
SOU !
revised 9/2/98 Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:#4050 Capt.Cook Lane Bld.#6 Center
Owner:Huntinge Mng.
Date of Inspection:01/27/2000
NRCS Report name
Soil Type
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth:Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Collar
Shallow wells
Estimated Depth to Groundwater 14+Feet
Please Indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
x Observed.Site(Abutting property,observation hole,basement sump etc.)
x Determined from local conditions
x Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators,Installers
t
Used USGS Date
Describe how you established the High Groundwater Elevation. Must be completed)
�t� ae— ����—cam•
revised 9/2/98 page 11 of 11
�\ COMMONWEALTH OF MASSACHUSETTS
z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
g d DEPARTMENT OF ENVIRONMENTAL PROTECTION
OqM SVOvp' RECEIVED
fr MAY 1 9 2003
TITLE 5 [RECEVED
WN OF BARNSTABLE
uFAl TH DEPT.
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASS-E-SSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 40-50(evens)Capt. Cook Lane,1Bldg.6,,Center Village
Owner's Name:c/o Huntingest Management
Owner's Address: Unit C,40 Industry Rd.Marstons Mills,MA 02648
Date of Inspection: 03/29/03 MAP
Name of Inspector:Brian T.Axon PARCH. .`- O 1 4---
Company Name:A&K Septic Systems Plus LOT
Mailing Address: 565 Carriage Shop Road East Falmouth,MA 02536
Telephone Number: 508-540-6706
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector.pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
X Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: � , Date: 04/18/03
The system inspector shall subunit a copy of this inspection report to the Approving Authority(Board of Health or i
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 subunit 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: System functioning fine. There is no evidence of failure criteria. System consists of 2000
gallon tank with d-box and 1-leaching pit with 4' of stone surround.
****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.
f
i
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:40-50(evens)Capt.Cook Lane,Bldg 6,Center Village
Owner: c/o Huntingest Management
Date of Inspection: 03-29-03
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303.
or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. I
{
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
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 than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:40-50(evens)Capt.Cook Lane,Center Village,Bldg 6
Owner: c/o Huntingest Management
Date of Inspection: 03/29/03
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.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well".Method used to determine distance
"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
v
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:40-50(evens)Capt.Cook Lane,Bldg 6,Center Village
Owner: c/o Huntingest Management
Date of Inspection: 03/29/03
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
x Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
x Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
x Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
x Liquid depth in cesspool is less than 6"below invert or available volume is less than'/2 day flow
x Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
x Any portion of the SAS, cesspool or privy is below high ground water elevation.
x Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
x Any portion of a cesspool or privy is within a Zone 1 of a public well.
x Any portion of a cesspool or privy is within 50 feet of a private water supply well.
x 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 system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface 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.
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:40-50(evens)Capt.Cook Lane,Bldg 6,Center Village
Owner: c/o Huntingest Management
Date of Inspection: 03/29/03
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks?
X _ Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection?
x _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out?
X _ Were all system components, excluding the SAS,located on site?
X _ 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?
X _ 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.
x _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)]
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 40-50(evens)Capt. Cook Lane,Bldg 6,Center Village
Owner: c/o Huntingest Management
Date of Inspection: 03/29/03
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 12 Number of bedrooms(actual) : 12
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 1320
Number of current residents: 15
Does residence have a garbage grinder(yes or no): no
Is laundry on a separate sewage system(yes or no):no [if yes separate inspection required]
Laundry system inspected(yes or no):NO
Seasonal use:(yes or no):no
Water meter readings, if available(last 2 years usage(gpd)):NA
Sump pump(yes or no): no
Last date of occupancy: current
COMMERCIALANDUSTRIAL
Type of establishment:
Design 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: system on regular maintenance schedule
Was system pumped as part of the inspection(yes or no):NO
If yes,volume pumped: Ballons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
X 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: 33 years, management co.
Were sewage odors detected when arriving at the site(yes or no):NO
r
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:40-50(evens)Capt.Cook Lane,Bldg 6,Center Village
Owner: c/o Huntingest Management
Date of Inspection: 03/29/03
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.):
SEPTIC TANK: x (locate on site plan)
Depth below grade: 0"
Material of construction: x concrete_metal_fiberglass polyethylene
_other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: standard 2000 gallon tank
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 34"
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: 7"
Distance from bottom of scum to bottom of outlet tee or baffle: 20"
How were dimensions determined:Field instruments
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
Recommend pumping every two years. Condition of tees and liquid levels are fine. There is no evidence of leakage.
Structural integrity is fine.
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 Address: 40-50(evens) Capt.Cook Lane,Bldg 6,Center Village
Owner: c/o Huntingest Management
Date of Inspection: 03/29/03
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade.-
Material of construction: concrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: x (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.):Distribution is equal. There is no evidence of solids carryover or any evidence of
leakage.
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Page 9 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 40-50(evens)Capt.Cook Lane,Bldg 6,Center Village
Owner: c/o Huntingest Management
Date of Inspection: 03/29/03
SOIL ABSORPTION SYSTEM(SAS): x (locate on site plan,excavation not required)
If SAS not located explain why:
Type
X leaching pits,number: I
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.):
No signs of hydraulic failure. Condition of vegetation and soil is fine.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) l
Number and configuration:
Depth—top of liquid to inlet invert.-
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.):
PRIVY: (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.):
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 40-50(evens)Capt.Cook Lane,Bldg 6,Center Village
Owner:c/o Huntingest Management
Date of Inspection: 03/29/03
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.
I
��31
L--i
z3
r� o
yo A
I-A2
, 4.
I
i
r+
revised 9/2/98 Page 10 of 11
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:40-50(evens)Captain Cook Lane,Bldg 6,Center Village
Owner: c/o Huntingest Management
Date of Inspection: 03/29/03
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 14+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:
x Observed site(abutting property/observation hole within 150 feet of SAS)
x 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:
Local conditions-site at high elevations
1 �2 h
19` �
7
I
D (:5k
FR$........�d:J.
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE
- Y
Apphratiun for Di-nVuiiul Wor1w Tamitrurtiun ramit
Application is hereby made for a Permit to Construct (�) or Repair (b�) an Individual Sewage Disposal
System at: ® 14-ti QM,ea L'
I i
......�.. --- --------------------•---••---•--•------ C ....................................................��—.�j� C.'u� c.nl
Q �;J� Location-: dye A- or Lot o, w�
Owner Address
w oYL�ioc GlI�Js'' 74E " �y gyp..------�/vl ''^'! 3�
,-� •------•--•-------------••----•----...---...----------------------------••......•--
Installer Address
UType of Building Size Lot............................Sq. feet
UDwelling— No. of Bedrooms---------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
a Other—Type of Building ---------------------------- No. of persons---------------------------- ( ) ( )
Showers — Cafeteria
04 Other fixtures ------------------------------- - -
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Li quid capacity...._...____gallons Length_.._.____..____ Width________________ Di ... Depth................
x Disposal Trench—.No. .............. Width------_------------ Total Length-------------------- Total leaching area_...................sq. ft.
3 Seepage Pit No---------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box O Dosing tank ( )
Percolation Test Results Performed by-------------............................................................. Date........................................
,`� Test Pit No. I----------- ---minutes per inch Depth of Test Pit-----_---__----___ Depth to ground water........................
(i, Test Pit No. 2.........::.....minutes per inch Depth of Test Pit.___----____.___-__- Depth to ground water..--_---..._-___--_-_.-.
a ----••••--••--------•--------------------•--.......---•-----•----••••••••••••-•-•--•-•---••-.................-••-•-•••-••-•••-••---•••---....................
0 Description of Soil........-'------------------•---------------•---------------•-----------------------------------•-------------------------------------------------------•••••..._...._..
x
W
•---- -------------------• ----------------------------------=--- ------------------------------------ - -- - -----------------------------------------------•--•--••-..........----
UNature of Repairs or Alterations—Answer when applicable.------�(- ' ��- ---• � s�-
-t �fi---------S L`u-J,...D-- w.°'b4------ �-.....�. 1�
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance ha ee issued b he and of health.
/
Signed ............... ..... ........ . ... .
Dace
Application,Approved By -------------- / .- ��.............. --------------------------------------------------- ....... ...7..'.?r
Application Disapproved for the following reasons:
�y Dace
Permit No. J� 1.. b Issued ----------------�y...- ...')---`----�57------
Date
�— ---- —��----��---------------------- ————— — ————
0 , C
No. 1�'-1.. .�� } Fas..............................
THE COMMONWEALTH OF MASSACHUSETTS
- _ BOARD OF—HEALTH
TOWN OF BARNSTABLE
Appliration for Diripwml Wor1w Tomitrnrtinn Permit
Application is hereby made for a Permit to Construct ( ) or Repair (t—j an Individual Sewage Disposal
. \
System at: j� � Q�yt M K-
....... ch Cf.,nJr�/C-vi u_ C� c s1 iN CctaIZ__ LAJ
-------------•-•-•-------•--------......---•-••--------............................. ------•••----•-----•--•--•---•--•••---------
C Location-:\ dress n or Lot No.
�a U�;,wEcS:' bLt(�------......-�_a --<_�l Mule =- (� '----- `.._.. ' ......----..•..---------
----------- --••- .....
Owner Address
W ZG ti�lJL._.G r� Cam(^J rs; 7 Cv� h. F y ip_ 1/V1 ` /�!1 t Address
Installer Address
d Type of Building Size-Lot............................Sq. feet
aDwelling— No. of Bedrooms--------------------------------------------Expansion Attic O Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) = Cafeteria ( )
Otherfixtures ----------------------------------------------------------------------- -------------- ----------------------------<
W Design Flow............................................gallons per person per day. Total daily flow.............c..............................gallons.
WSeptic Tank—Liquid capacity------------gallons Length---------------- Width________________ Diameter----- .......... Depth................
x Disposal Trench—No_ ____________________ Width-------------------- Total Length-------------------- Total leaching area....................sq. ft. y
Seepage Pit No---------_........... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1________________minutes per inch Depth of Test Pit___-__-.---__-_____- Depth to ground water_._-_-_-_____-_______-_.
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
W •---•••--•-----------------••----••-•-••-•......•--•--••----•......------•-••-----•••••••-•--------.........................................................
0 Description of Soil........................................................................................................................................................................
W
U ...............•-------•--•-••--•---•-....--•---••-----•••-----••-••---•-------•••-------•-----•----•-•-•-•-•--------••---•----------...-------•----•••-•----•-...-•------...........--••--•-•--._......
W
UNature of Repairs or Alterations—Answer when applicable._-___v �`t ✓ ....... .......
...... .. .:Y �i�sl r--� �,�( v� 5`�= � t T" v '`�,J O W ,;7-t —
--- ------- ----- •......................................... �
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance hjas%bee�c`ssued bJy Vhe�,Qard of health.
Signed -------------_/-- fit>w'.I. ( / ......
Dare
Application.Approved By ----------------- .. ` .�-'^-�- �.... ......W............ .... .... .. -------�...- � �.
Dare
Application Disapproved for the following reafonf: ...................................................................................
---------------------------------- ---- ------------------------------------------------------------------------------------------------------------ ---------------------------- -------------- ........................................
Date
- 1j(- 7.. Issued �Permit No. 7.5 ............... ......_..- .....
r Date
THE COMMONWEALTH OF MASSACHUSETTS 7 71-1—Q),Y
BOARD OF HEALTH
TOWN OF BARNSTABLE
Cer#tfira e of VILloraplt2 ace
THIS IS TO CELZ_TI�5Y, That the Individual Sewage Disposal System constructed ( ) or Repaired (� )
by ........................................../--� - ' LJ�c1. _... «l-s - 1 C—i7 o,v
----------------------------------------------- ----- -----------------------------------------
�—y�� _ Installer i
SS r/I,s C .Gur�.....L.e�1....... c2 6+Ja�Vtt;I.��_ C��Ai
at ...............----------------------------.._--------------------------------------- --- -----------------------------------------
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ... , 1C.'...1. �.. ...,��.. dated _6._y.. .-..�i��-__..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED-AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE _....4..... ..._...1... _....F/....->�'�_----------- -------------- Inspector-.. 6' "' s�"✓t-k /,-
-------------- ----------------- --------- - --_--_------ ----=
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
� - l�y�
TOWN OF BARNSTABLE \
., No._. ..,3-,-----.... s FEE.....:FQ..........
i n ttl nrkii Tomitrurtion Permit
U Permission is hereby granted----- ...1�. ..�.._-..-------------------------'-------mow T•- -U---�-�--------------------•-----...------....-----..
to Construct ( or Repair an Individual Sewage Disposal System
yc� �� �at No.............. 6---------P-..&......... ..... . .....--- L -r--- -------- bLt...........------.....- '-''......`-
Street �. t —No.
-........_..
----------•-••-•----••--..._ ',;;,------------------ .............................................
V Board of Health
DATE....... 2---`--�- ---•-••-57�•--••-...-••••---•--••-•-•-----.... ,
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS
, �1"� OWN OF BARNSTABLE
,,/ s--
L�JCATION i0 ein G6,4/C za✓7e- SEWAGE #
MLAGE(2a4�'e_ //yANA"5 ASSE SOR''S MAP
/& LOT '
NAME&PHONE NO.Ar 70 044 �n
SEPTIC TANK CAPACITY � r
LEACHING FACILITY: (type) i �J (size)
NO.OF BEDROOMS
BUILDER OR OWNE /���✓AG Eh' Geri �5�` CJz U
PERMITDATE: - COMPLIANCE DATE:
Separation Distance Between the:
i
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility oA 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 fac' 'ty) _ / Feet
Furnished by A 72VAS�7 LAG'+`/ � X,_ All
�,
l� ��
A
7
�C�"T S�� -- '�
,ln��
�� o��
��� ag./
• 11 ._
��� �'