HomeMy WebLinkAbout63-77 CAPTAIN COOK LANE - HYANNIS CONDOS 63-77 Captain Cook Lane
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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 SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address 63-77 Captain Cook Lane I �j� A
Building 8
Center Village,Hyannis,MA
Owner's Name Multiple Owners
Owner's Address Huntingest Property Management
40 Industry Road—P.O.Box 340
Marstons Mills,MA 02648
Date of Inspection ' Ol/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 781-383-1.234
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: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 orhas 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.
VU
1
Title 5 Inspection Form 6/15/2000
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 A
CERTIFICATION(Continued)
Property: 63-77 Captain Cook Lane/Building 8
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:
BI 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
(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:63-77 Captain Cook Lane/Building 8
Center Village,Hyannis MA
Owner: Multiule Owners
Date: 01/22/09
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 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:63-77 Captain Cook Lane/Building 8
Center Villa-ee,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 I 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.]
N_O(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 H of a
public water supply well)
4
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:63-77 Captain Cook Lane/Building 8
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.
A- This page intentionally left blank
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:63-77 Captain Cook Lane/Building 8
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)]
I
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: 63-77 Captain Cook Lane/Building 8
Center Village,Hyannis,MA
Owner: Multiple Owners
Date: 01/22/09
FLOW CONDITIONS
RESIDENTIAL:
Number of bedrooms(design): Number of bedrooms(actual): 16 units.
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
Number of current residents: Number varies but typically 22 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/sqft,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 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:
TYPEiOF 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
I
7
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: 63-77 Captain Cook Lane/Building 8
Center Village,Hyannis,MA
Owner: Multiple Owners
Date: 01/22/09
This page intentionally left blank
s
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:63-77 Captain Cook Lane/Building 8
Center Village,Hyannis,MA
Owner: Multiple Owners
Date: 01/22/09
BUILDING SEWER(locate on site plan)
Depth below grade: 51".
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: 42".
Material of construction: X concrete metal Fiberglass Polyethylene
other(explain)2,000-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: 6'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:63-77 Captain Cook Lane/Building 8
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 c r 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 (617)545-2800 (617)749-6178
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART C
SYSTEM INFORMATION(Continued)
Property: 63-77 Captain Cook Lane/Building 8
Center Village,Hyannis MA
Owner: Multiple Owners
Date: 01/22/09
SOIL ABSORPTION SYSTEM(SAS): YES.(locate on site plan,excavation not required)
i
If SAS not located,explain why:
Type:
X leaching pits,number: 2—8'deep X 6'wide 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 si ns of hydraulic failure observed.Both pits had 4'of water in them.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
LTitle5ction 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:63-77 Captain Cook:Lane/Building 8
Center Village,Hyannis,MA
Owner: Multiple Owners
Date: 01/22/09
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.
4 5
8 deep x h Wide ®�
_ Lej.9h(an t,
0
_-
O -A -- 3 /6 ' 13 . 3
l —4 26 ' 13 - 4 = l 0.'
C — 67,
NO s Cale,
12
Title 51nSDection 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: 63-77 Captain Cook Lane/Building 8
Center Village Hyannis MA
Owner: Multiple Owners
Date: 01/22/09
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:
During previous inspections the high groundwater was indicated to be 19' 6" below grade Clearly there is separation from the
bottom of the SAS to the hi h roundwater 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.
l
13
Title 5 Inspection Form 6/15/2000
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
d DEPARTMENT OF ENVIRONMENTAL PROTECTION
L
FEB 0 1 2005
TOWN OF Bk. -NSTABLE
TITLE 5 HEALTH DEPT.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION QQ��
Property Address: 63-77 Captain Cook Laue,Bldg#$.,Center Village MAP
1�iYA N 1 PARCEL ; O 1 4-
Owner's Name: c/o Huntingest Management -- ---
Owner's Address: Unit C,40 Industry Rd.Marstons Mills,MA 02648 LOT
Date of Inspection: 01/13/05
Name of Inspector:Brian T.Axon
Company Name:A&K Septic Systems Plus
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: — A Date: 01/20/05
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments: System functioning fine.There is no evidence of failure criteria. System consists of 2000_.
gallon tank with d-box and 2 leaching pits. :
""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 samelor different
conditions of use.
� 2
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 63-77 Captain Cook Lane,Bldg#8 Center Village
Owner:c/o Huntingest Management
Date of Inspection: 01-13-05
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 CUR 15.303
or in 310 CUR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
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
r
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 63-77 Captain Cook Lane,Center Village Bldg 8
Owner:c/o Huntingest Management
Date of Inspection: 01-13-05
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(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 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:
Page 4of11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 63-77 Captain Cook Lane,Bldg 8
Owner: c/o Huntingest Management
Date of Inspection: 01-13-05
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 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.]
__no (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CUR 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 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
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 63-77 Captain Cook Lane,Bldg 8
Owner: c/o Huntingest Management
Date of Inspection: 01-13-05
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: 63-77 Captain Cook Lane,Bldg 8
Owner: c/o Huntingest Management
Date of Inspection: 01-13-05
FLOW CONDITIONS
RESIDENTIAL •
Number of bedrooms(design): 16 Number of bedrooms(actual) : 16
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 1600
Number of current residents: 15
Does residence have a garbage grinder(yes or 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)):
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: last pumped roughly 1 year ago,property manager
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
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) 3
=Tight tank _Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed(if known)and source of information:20+years,management co.
Were sewage odors detected when arriving at the site(yes or no):NO
Page 7of11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 63-77 Captain Cook Lane,Bldg 8
Owner:c/o Huntingest Management
Date of Inspection: 01-13-05
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: 18"
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: 10.5 x 6 x 5
Sludge depth: 5"
Distance from top of sludge to bottom of outlet tee or baffle:44""
Scum thickness: 3"
Distance from top of scum to top of outlet tee or baffle: 9"
Distance from bottom of scum to bottom of outlet tee or baffle: 14"
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: 63-77 Captain Cook Lane,Bldg 8
Owner: c/o Huntingest Management
Date of Inspection: 01-13-05
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.):Box is level.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.):
I.
I "
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 63-77 Captain Cook Lane,Bldg 8
Owner:c/o Huntingest Management
Date of Inspection: 01-13-05
SOIL ABSORPTION SYSTEM(SAS): x (locate on site plan,excavation not required)
If SAS not located explain why:
Type
X leaching pits,number: 2
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Typetname 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)
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 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORA
PART C
SYSTEM INFORMATION (continued)
Property-Address: 63-77 Captain Cook Lane,Bid-8
Owner: c/o Huntingest Management
Date of Inspection: 01-13-05
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.
C
r_.
C.7'
t. L-1 3 i
Li°'
Page 11 of 11
OFFICIAL-INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 6347 Captain Cook Lane,Bldg 8
Owner: c/o Huntingest Management
Date of Inspection: 01-13-05
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 19+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:
1 t�
ti � ► t
1
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
MAP --
PAM • ® 1 o x
LOT :
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:69 Captain Cook Lane,B g 0 Center Village O��
Owner's Name:c/o Huntingest Management �Y�
Owner's Address:Unit C,40 Industry Rd.Marstons Mills,MA 02648
Date of Inspection:01-2842 RECEIVED
Name of Inspector:Brian T.Axon F E B 14 2002
Company Name:A&K Septic Systems Plus
Mailing Address:565 Carriage Shop Road East Falmouth,MA 02536
TOWN OF BARNSTABLE
HEALTH DEPT.
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 fimction 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; 01-29-02
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments: System functioning fine.There is no evidence of failure criteria. System consists of 2000
gallon tank with d-box and 2 leaching pits.
****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.
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:69 Captain Cook Lane,Bldg#S Center Village
Owner:c/o Huntingest Management
Date of Inspection:01-28-02
Inspection Summary: Check AA,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.
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 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner.c/o Huntingest Management
Date of Inspection:01-28-02
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.
i
3. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:69 Captain Cook Lane,Bldg 8
Owner:c/o Huntingest Management
Date of Inspection:01-28-02
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 m 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%Z 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 fai s.I have determined that one or more of the above failure criteria exist as
described in 310 CUR 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 R 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
nil.+.i♦•—t fh—nt—4—Cantinas T7—Fnllo.i s—A—Cn-fin»11 ohnll nwr A.A.ciic+.—in--An—..4h Z I A
f '
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:69 Captain Cook Lane,Bldg 8
Owner:c/o Huntingest Management
Date of Inspection:01-28-02
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
_ _ 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'J
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 an of the failure criteria related_ ( y t 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:69 Captain Cook Lane,Bldg 8
Owner:e%Huntingest Management
Date of Inspection:01-28-02
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 16 Number of bedrooms(actual): 16
DESIGN flow based on 310 CMR 15,203(for example: 110 gpd x#of bedrooms): 1600
Number of current residents: 15
Does residence have a garbage grinder(yes or 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:
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
ivy
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 i Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed(if known)and source of information:20+years,management co.
Were sewage odors detected when arriving at the site(yes or no):NO
i
-Page 7 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:69 Captain Cook Lane,Bldg 8
Owner:clo Huntingest Management
Date of Inspection:01-28-02
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: 18"
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: 10.5 x 6 x 5
Sludge depth:T'
Distance from top of sludge to bottom of outlet tee or baffle: 41"
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: 14"
How were dimensions determined:Field instruments
Comments(on pumping recommendations,inlet and outlet tee or bale 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.):
f
Page 8 of k 1
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:69 Captain Cook Lane,Bldg 8
Owner:c/o Huntingest Management
Date of Inspection:01-28-02
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.):
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 II
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:69 Captain Cook Lane,Bldg 8
Owner:c%Huntingest Management
Date of Inspection:01-28-02
SOIL ABSORPTION SYSTEM(SAS): x (locate on site plan,excavation not required)
If SAS not located explain why:
Type
X leaching pits,number: 2
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)
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: l
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: 69 Captain Cook Lane,Bldg 8
Owner:c/o Huntingest Management
Date of Inspection:01-28-02
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.
A
AD a7'
Ar 431
C y9'
4& 1a'
C G 3H'
Page l l of l i'
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 69 Captain Cook Lane,Bldg 8
Owner:c/o Huntingest Management
Date of Inspection: 01-28-02
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 20+feet
Please indicate(check)all methods used to detcxrnine 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)
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:
Paperwork filed at town hall.
INV
21 7
1
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:69 Captain Cook Lane,Bldg 8
Owner:c/o Huntingest Management
Date of Inspection:01-28-02
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 20+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)
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:
Paperwork filed at town hall.
i
TOWN OF BARNSTABLE
`OCATION 6 3-� 'gc)n Cody, L U n SEWAGE #
VILLAGE (eAt 4e ASSESSOR'S MAP & LO .X
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 000 9.,J O 1
LEACHING FACILITY: (type) - i A i (size) ztt�Y-,$
A NO.OF BEDROOMS iy' 6-ekdynns
BUILDER OR OWNER
PERMTTDATE: a COMPLIANCE DATE:
Separation Distance Between the: A ►i
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 acility) Feet
Furnished by — ._ y
CO) 0 A
tRachl-i P74
At) 971
130 539
AE 3'
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ci yil
13C 0'
C� 3y�
T OF rBNS TABLE
j
u LOCATION �. ) o SEWAGE #
VILLAGE Y �N�= ASSESSO ' MAP& LOT d1�1. OiY
77�=
AME&PHONE I`5C6�NOj.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) /DDI�.. 4dV (size)
NO.OF BEDROOMS
BUILDER OR O R � N
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility J ! Feet
Private Water Supply Well and Leaching Facility (If any wells exist ,,/
on site or within 200 feet of leaching facility) I Feet
Edge of Wetland and Leaching Facilit (If any wetlands exist
within 3 of leachin facil' Feet
Furnished by
1`
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if
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