Loading...
HomeMy WebLinkAbout0049 ISALENE STREET - Health �49 Isalene Street x Hyannis P A 267 152 I x Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 49 Isalene Street Property Address Tom OToole Owner Owner's Name information is required for every ►Vest lHyaAaisport S MA 02672 11/06/11 page. CitytTown zbl I state Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael Kellett use the return Name of Inspector key. Aardvark Environmental Inspections Company Name P.O.Box 896 Company Address East Dennis MA 02641 Cityrrown State Zip Code 508-385 7608 S13742 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 16.000).The system: . ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority ma,t�Lf �� 11/08/11 Inspect is Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•11/10 Title 5 Official Inspection Form.Subsurface Sewage Disposal stem•Page 1 of Commonwealth of Massachusetts Title 5 official Inspection Forma Subsurface Sewage Disposal System Form Not for Voluntary Assessments 49 Isalene Street Property Address Tom OToole Owner Owner's Name information is required for every West Hy p annis ort MA 02672 11/06/11 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary:Check A,B,C,D or E./always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Check the box for"yes","no"or"not determined" (Y,N, ND)for the following statements.If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 r ' Commonwealth of Massachusetts Tithe 5 official Inspection Fora s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 49 Isalene Street Property Address Tom OToole Owner Owner's Name information is required for every west Hyannisport MA 02672 11/06/1'1 i page, CitylTown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced: ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage.Disposal System Form-Not for Voluntary Assessments 49 Isalene Street Property Address Tom OToole Owner Owner's Fume information is required for every West Hyannisport MA 02672 11/06/11 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the system is functioning in a mannerthat protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6"below invert or available volume is less than'/day flow t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 49 Isalene Street Property Address Tom OToole Owner Owner's flame information is required for every west Hyannisport MA 02672 11/06/11 page. City/Town state Zip Code Date of Inspection B. Certification (cost.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑' ® Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails.i have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either"yes" u or non to each of the following,in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a.nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well if you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 5Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 49 Isalene Street Property Address Tom OToole Owner Owner's Name information is required for every West Hyannisport MA 02672 11/06/11! page. City(Town State Zip Code Date of rnspection C. Checklist Check if the following have been done.You must indicate`yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? P 9 ® ❑ Were all system components,excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction, dimensions,depth of liquid,depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example,a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 49 Isalene Street Property Address Tom OToole Owner Owner's Name information is West Hyannisport MA 02672 11/06/11 required for every page. Cityrrown state Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ® Yes ❑ No Water meter readings,if available(last2 years usage(gpd)): i Detail: Sump pump. ❑ Yes ® No 08/11 Last date of occupancy: Date Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft.,etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings,if available: •Page'of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposals System Form-Not for Voluntary Assessments 49 Isalene Street Property Address Tom OToole Owner Owner's Name information is required for every West Hy p annis ort MA 02672 11/06/11 page. CityJTown State Zip Code Date of Inspection D. System Information (cunt.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank,distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (f yes,attach previous inspection records,if any) ❑ Innovative/Altemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the VA system by system operator under contract ! ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): i t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage.Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 49 Isalene Street Property Address Tom OToole Owner Owner's Marne information is required for every West Hyannisport MA 02672 11/06/11 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Approximate age of all components,date installed (if known)and source of information: 06/10/92 per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.7 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting,evidence of leakage,etc.): Septic Tank(locate on site plan): Depth below grade: 1.0 feet Material of construction: ®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal,list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: 3 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 49 Isalene Street Property Address Tom O'Toole Owner Owner's Name information is required for every west Hyannisport MA 02672 11/06/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 27" Scum thickness 2" 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 15" How were dimensions determined? measured Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): The tank was sound and tight with tees in place and liquid at outlet invert. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11f10 TMe 501 ria4 tnspecton Form:Subsuftce Sewage Dtsposai S`stem=Page 10 of 17 Commonwealth of Massachusetts Tine 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 49 Isalene Street Property Address Tom OToole Owner Owrt&s Name information is required for every West Hyannisport MA 02672 11/06/11 page CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches,etc.): Attach copy of current pumping contract{required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 49 Isalene Street Property Address Tom OToole Owner Owner's Name information is required for every West Hyannisport MA 02672 11/06/11' page. Cityrrown state Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert even 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.): The box was level and tight with no sign of carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located,explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 49 Isalene Street Property Address Tom OToole Owner Owner's Name information is required for every West Hyannisport MA 02672 11/06/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ 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.): This system has a 6'x6'precast pit surrounded by 2'of stone.There was a puddle in the bottom of the pit with a stain line 26"up from the bottom. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5fns-11110 Tffe 5 Official inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s, Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 49 Isalene Street Property Address Tom OToole Owner Owner's Name information is required for every West Hyannisport MA 02672 11/06/11 page. Cityrrown State Zip Code Date of Inspection D. System Information (cant.) 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.): I t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts -- Title 5 Official Inspection For Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 49 lsalene Street Property Address Tom OToole Owner Owner's Name information is West Hannisport MA 02672 11/06/11 y required for every State Zip Code Date of inspet#ion page. Qtyrrown ®. System Information (cont.) Sketch Of Sewage Disposal System:Provide a view of the sewage disposal system,including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately I i i �Q 3c� - j Titl .F e 5 Official inspection form:subsurface 9ewa9e Disposal System•Page 15 of 17 t5ins•11110 i Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 49 Isalene Street Property Address Tom OToole Owner Owner's Name information is required for every West Hyannisport MA 02672 11/06/11 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 20.0 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked,date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database explain: You must describe how you established the high ground water elevation: USGS maps show an elevation of over20.0 feet. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins•11/10 Title 5Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 49 Isalene Street Property Address Tom OToole Owner Owner's Na1ne information is required for every West Hyannisport MA 02672 11/06/11 page. Ckylfown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C,D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file I � t5ins-11/10 Title 5Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 k " �u `i :°F a+ t ks t Y r ya O �Lf7 '� vo. ait °�a �q" �. pt�y4�"`i b "fil i � "Y"s+`ti"�, �t,q'zxi ��d"� YF'" sa a",v ,4?'a, AA .t 3 RECEIVED'FROM " ''`' "t. --DOLLA rAl mr �ACCOUnt Total �� v a a ® F FmxF' ,, q Amo6nt P-�d,,Q$lr r k � s r!tlk,ems .' atty "Wrr e sv F a `' P M n � s aaa �c •'`' + COMMONWEALTH OF MASSACHUSETTS • EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTIO TITLE 5 OFFICIAL INSPECTION FOR1tiI—NOT FOR VOLUNTARY ASSESSMENTS (t SUBSURFACE SEWAGEI " PART A DISPOSAL SYSTEM O�,I 3-6 /( CERTIFICATION PARCEL : 1 Sl ProPerty Address• / �S / H e S LCY --- est Owner's Name: Uli,lb a, a' nc,/ �CEIVE:D Owner's Address: /e�� S f o���� Date of inspection: / JAN 2 12003 Name of Inspector•. (please print) 7� ,VN of BARNSTABLE Company Name: / v�2 t FIEc^LTH DEPT. bl:Win � Ad g dress: 6 Telephone Number. CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address below is true,accurate and complete as of the time of the• and the information reported training and eeperience in the proper function and inspection The inspection was performed based on my approved system inspector pursuant to Section 15.340e of Titlf on e 5 site CMa 1S,Opp�ry�ms•I am a DEP ). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fail Inspector's Signature: , L Date: The system inspector sbaa submit a copy of this Dom')within 30 days of completing this inspection.mspectron report to the Approving Authority(Hoard of Health or gpd or greater,the inspector and the systemv er�e system u a shared system or has a design flow of 10,000 DEP.The on ' submit�nPon to the appropriate regional office of the gutal 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 time.This inspection does not address how the system will at that conditions of use. Perform in the future under the same or different Page 2 of l l OFFICIAL INSPECTION FORNj—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR1*I PART A CERTIFICATION (continued) Property Address: LL T��9 15e,l e"e S Owner. °f *Lu►1- S4 Oo e Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. �V! Passes: y have 15.303 or in 310 CbfR15 304 exist. Any failure indicates a �t anv of the failure criteria described evaluated are indicated below. in 310 C1�iR Comments: B• System Conditionally Passes: L One or more system components as described in the-Conditional pass or repaired.The system,upon completion of the replacement or re section need replaced Pair,as approve d by the Boardd off Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements If"not det explain ermined"please The septic tank is metal and over 20 years old*or the septic unsound,exhibits substantial infiltration or exfil tank whether metal or not)is structurally tratton or tank failure is tmmin=L S *'wing tank is replaced with a complying septic tank as approved Ystem will pass inspection if the A metal septic tank will pass inspection if it is indicating that the tank is less than ZO years old stis availtaltableru by the Beard of Health P ctuy. ,not leaking and if a Certificate of Compliance , .sound ND e`cplain: Observation of sewage backup or break out or high static water level Obstructed pipe(s)or due to a broken,settled or uneven in the distribution box due to broken or approval of Board of Health): distribution box. System will pass inspection if with 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: II Page3ofll OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR1tiI PART A n CERTIFICATION(continued) Property Address: 7 A 16,4 e Owner: Date of Inspection: 3 O Z C- Further Evaluation is Required by the Board of Health: /y Conditions e:dst which require Ruther evaluation by is failing to protect public health,safety or the environment_the Board of Health in order to determine if the system L System will pass unless Board of Health determines in accordance with 310 CIVIR 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 Z System will fail unless the Board of Health system is functioning in a manner that protects(and heWater lth safety annd if any) that the _ The system has a septic tank and soil absorption system(SAS)and the SAS is surface water supply or tributary to a surface water supply. within 100 feet of a 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 failure criteria are triggered.A copy of the analysis must be attached s this form Provided that no other 3• Other- Page 4 of I l OFFICIAL INSPECTION FORINI_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1S5.1 v)p S� Owner. Date of Inspection: d 3 D. System Failure Criteria applicable to all systems: You must indicate"yes" or"no"to each of the following for all inspections: Yes N / V—,.-Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspoo( _ 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 o— /cesspool clogged SAS or V Liquid depth in cesspool is less than 6"below invert or available volume is less than y=day flow Required pumping more than 4 times in the last year NOT due to clogged /of times pumped geed or obstructed pipe(s).Number Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface .,-water supply. !/�Any portion of a cesspool or privy is within a Zone I of a public well. Ahy orti portion of a cesspool or privy is within 50 feet of a private water supply well. b� Any portion of a cesspool or privy is less than 100 feet but great supply well with no acceptable waterer than 50 feet from a private water �'�Y�performed at a DEP certified laboratory,for colifo(This system passes if the well water analysis, rm 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 e.•ist 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 la be system the system must serve gpd. a facility with a design flow of 10,000 gpd to 15,000 You must indicate either"yes-or"no"to each of the following: (Thd 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'Me owner or Operator of an large significant threat under Section E or failed under Section D shall u Y g system considered a 15.304.The system owner should contact the a p�de the system in accordance with 310 CUR appropriate regional office of the Department. Page 5 of 1 I OFFICIAL INSPECTION FORD[-NOT FOR VOLUNTARY ASSESSI�I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM TSOR PART B CHECKLIST Property Address: •L���p�� Owner-._A2 1`y Date of Inspection• 77) Check if the followin have been done. You must indicate``ves"or"no"as to each of the followin ; Yes o Pumping information was provided by the owner,occupant,or Board of Health t! Were any of the system components pumped out is/ the previous two weeks Has the system received normal flows in the previous two week period t/ Have large volumes of water been introduced to the system recently or as of Part this inspection Were as built plans of the system obtained and examined?(If they were not available note as N/A) i — Was the facility or dwelling inspected for signs of sewage/ g back up �G Was the site inspected for signs of breakout kzzWere all system components,excluding the SAS, located on site Were the septic tank manholes uncovered,opened, es or tees,material of construction,dimensi and the interiorof the tank inspected for the condition ns,depth of liquid,depth of sludge and depth of scum Was the facility owner(and occupants if different from owner maintenance of subsurface sewage disposal systems )provided with information on the proper Y��ncoThe sae and location of the Soil Absorption System(SAS)on the site has been determined based on: Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria lated w part C is at issue approximation of distance is unacceptable) [310 Chin I5.302(3)(b)] re Page 6 of l 1 OFFICIAL INSPECTION FORINI—NOT FOR VOLUNTARY ASSESSv SUBSURFACE SEWAGE DISPOSAL SYSTEM PSPECTION FORM1ENTS PART C SYSTEM FORMATION Property Address: 2� 5��•/4PPle s/L Owner, vti7--e Date of Inspection: /4 RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design): .3 Number of bedrooms DESIGN flow based on 310 C1yR 15.203 (for example: 110 (actual): of current residents:�_ x#of bedrooms): Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no):—,PJ C��,� Laundry system inspected(yes or no):41V separato inspection required] Seasonal use: (yes or no): Water meter readings,if available(last 2 years usage(Spd)): Sump Pump(yes or no): / 0 Last date of occupancy: r L4 COMAIERCLUAND USTRIAL Type f establishment: Design flow(based on 310 CUR 15.203):_ 8pd Basis of design flow(seats/persons/sgft etc.): Grease tMP Present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title�$ S Water meter readings,if available; system(Yes or no): Last date of occupancy/use: OTHER(describe): Pumping Records / GENERAL INFORMATION Source of information: "v0 T /e" v./ 1 Was system pumped as part of the inspection es or no):vp If yes,volume pumped:_gallons—How was Reason for pumping: T= 'Pumped determined? TYP OF SYSTEM Septic tank,distribution box,soil absorption system _Single cesspool 6erflow cesspool —Privy Shared system(yes or no)(if yes,attach previous inspection records,if an InnovativelAlternative technology.Attach a copy.of the y) obtained from system owner) Arent operation and maintenance contract(to be Tight tank _Attach a copy of the DEP approval Other(describe): APPrOXimate age of all components,date installed( � )and (� of information: Were sewage odors detected when arriving at the site(yes or no): �(1 Page 7 of It OFFICIAL INSPECTION FORINI—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEIN1 INSPECTION FORM SYSTEM PART C MFO MI ATIO N(continued) Property Address: Y 6+kF Owner. vo 1 Date of Inspection: D BUILDING SEWER(locate on site plan) Depth below grade: / Materials of construction:_pst iron ✓40 puC Distance from private water supply well or suction line:other(explain): Comments(on condition of joints,venting,evince of leakage,etc.): SEPTIC TANK. ANK._(locate on site plan) Depth below grade; Material of construction: 1, oncrete metal_fiberless —other(explain)ain) _polyethylene If tank is metal list age:_ Is age confirmed certificate) by a Certificate of Compliance(yes or no):_(attach a copy of Dimensions: Sludge depth. i Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: _/ _ =—L— Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee Qr baffle: /� How were dimensions determined: v/� K Comments on ude, ( pumping recommendations,u>,et and au et tee or baffle condition,structural integrity,liquid levels as fated to outlet invert,�evidencx of j ge,etc.): 07C , GREASE TRAP:/!✓(locate on site plan) Depth below grade: Mat lof construction concrete_metal_fiberglass_pol (explain). yethylene_ocher 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 bZ Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle conditio as related to outlet invert,evidence of leakage,etc.): ii,structural integrity,Liquid levels page 8 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSM SUBSURFACE SEWAGE DISPOSAL ENTSSYSTEM INSPECTION FOR PART C 1�I p SYSTEM FOR,-.I (continued) ProPerty Address: / le f z - � Owner. QJ 7� Date of Inspection: TIGHT or HOLDING TANK: N (tank must be Piped at time of inspec-tion)(locate on site plan) Depth below gr c: Ivtaterial of construction: concrete mesa! 'fiberglass_polyethylene other(explain). Dimensions; Capacity: rLons Design Flow: eallons/dav 'vam present(yes or no): Alarm level: Alarm in workingorder Date of last pumping: (yes or no):— Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: "(-'(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert Comments(note if box is level and distribution l to outlets equal,any evidence of solids leakage into or out of box,etc.): carryover,any evidence of PUMP CHAMBER locate on site plan) Pumps is working order(yes or no): Alarars in working order(yes or no): Continents(note condition of pump chamber,condition of Pimps and appurtenances,etc.): i t r 4 Page 9 of l l OFFICIAL INSPECTION FORMI-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM[ INSPECTION FORM M PART C SYSTE �J �O"IATION(continued) Property Address: 7 '..7.1"0 U/eps� Owner. . a S `� Date of Inspection• /� IF SOLI.ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type , leaching pits,number.L -ly, ,6 L-✓/� — leaching chambers,number. — leaching galleries,number leaching trenches,number,length: leaching fields,number,dimensions-.-------- -overflow cesspool,number. innovativelalternative system Typelname of technology: Comments(note condition of soil,signs of hydraulic fart etc.): / _ ire,level of ponding,damp soil,condition of vegetation, _// CESSPOOLS: -(cesspool must be pumped as part of motion ovate )(I 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 n po ding.condition of vegetation,etc.): PRIVY: /t/(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 FORNI SYSTEM INFO�,PART C �ff IATION(continued) Property Address• `T TSI lP/tie .s} Owner, p Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two benchmarks.Locate all wells within 100 feet.Locate where Permanent reference landmarks or Public water supply enters the building. 14 -671 G r, l 3 6,�-- 3v' A { Page 11 of 11 OFFICIAL INSPECTION FORD[_NOT FOR VOLUNTARY ASSESSME SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOB TS SYS PART C !�(7 TEM INFOMIATION(continued) Property Address: Owner, �� a►✓i.�, _ %� D,� Date of inspection: SITE EXAM Slope . Surface water Check cellar Shallow wells Estimated depth to -� dep ground water/ �;feet Please indicate(check)all methods used to determine the high ground water elevation: __Obtained from system design plans on record.If checked,daze of design Observed site(abutting Property/observation hole within 150 feet of SAS) _-Checked with local Board of Health-explain __Checked with local excavators,installers-(attach�vmentation) Accessed USGS database-e:cp[ain: You st describe how you established a high g M.und water elevation: 0 i t °Cry S L Nn w- t t I e 4 TOWN OF BARNSTABLE LOCATION � �A! � �$( SEWAGE # 1 -,)(f� VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. �-Q�(�t yp'Seow c SEPTIC TANK CAPACITY j(}'Y'Dc'7 LEACHING FACILITY:(type) QR`�-S ST P/T (size) j NO. OF BEDROOMS PRIVATE WELL O PUBLIC-_._.� 4" BUILDER OR OWNER DATE PERMIT ISSUED: '�P DATE COMPLIANCE ISSUED.: A VARIANCE GRANTED: Yes No 9- No... . :2. — Fss..��.a........ THE COMMONWEALTH OFMASSACHUSETTS 2:. BOAR® OF HEALTH TOWN OF BARNSTABLErtment ApV iraftou for Disposal Works TVUS e sue' Application is hereby made for a Permit to Construct ( ) or Repair (k,-,Kn Individual Sewage Disposal System at: y �3a r�............ ... -- ---... Location - ddre_...... �.... - ------------------------------------------ ------ {/,�) Location)'Alnddress �+y����,,,,p or Lot No. ................"°� .Q.!_:S_Y... -Y.P-��.................... 4 .!. .f!!_�.d................--^•--•--.............................. . Owner Installer Address d Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms .........-....---------------•--_Ex Garbage ( ) U — ( ) a Expansion Attic ( ) Grinder li aOther—Type of Building ............................ No. of persons................--.......... Showers ( ) Cafeteria Otherfixtures ....................................---.............. ••-•------••---••---------........•••••---••-----._.......•--•-•---•-••..............---------- W Design Flow.......'S. ........................gallons per person, day. Total daily flow...... 3 ................_....gallons. WSeptic Tank Liquid capacity .gallons Length....Y...__...... Width--- -_____.... Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-----I------------- Diameter..__ ..... Depth below inlet---62e ......... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by...................................................•-•-••--•-•---••----- Date........................................ W 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........................ P4 ....-•-•-••--------------------••-------••-••--------••---------•------•------•-.....---••---.------.... 0 Description of Soil...............................................................................-----------------------•---------- W x - ��es��d V Nature of Repairs or Alterations—Answer when applicable.._______ ______ _______________�____1_ _.`S ..... , '17 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 I system in operation until a Certificate of Compliance has bew issue the boar of health. Signed .---.. ._.... ..._.... 4-' '= _7•�► Dace Application Approved BY 0 Ls --^-j----------------------------------------------------------------------------- ---------- Dare Application Disapproved for the following reasons- ---- --------------------------------- ---- ---- --- ---- ----------------- -- -------------- ------------. ---------------------------------------- C� L Dace Permit No. ./......rt-.-.... ¢-:�"'------------------- Issued Dace 7� .. - No....• .... FEs. _ ............... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF " HEALTH TOWN OF BARNSTABLE 0 -Z;A A lir�ation for Disposal larks C> onstrur W , ° rr�t Application is hereby made for a Permit to Construct ( ) or Repair (,,-)'an Individual Sewage Disposal System at: ..--•-••-•-... ......L S mil. L=lV I= S /� i ail n,�v' Ilr�r' .....----•----................................................... --•--...-...;. ; ._..... = ......--.......................................... Location-Address or Lot No. ..............�''1/1 Wl—E'.............................................................. W Owner Address _ /� n : 14 �t K1f`/�'1 L/ C t ------••--•-----•--•._......-•--•••---•r......................................................... ......................y -•----•-........ -•-•............------............................. Installer ' Address Type of Building Size Lot............................Sq. feet V t•-t Dwelling—No. of Bedrooms... ...................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures . W Design Flow_ ..F .........................gallons per person per day. Total daily flow---- .......................gallons. WSeptic Tank/—Liquid capacity.42Q...gallons Length_✓._......... Width' ............ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No._.et............... Diameter...).t?'.__..... Depth below inlet.L-Z............ 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..................... fZq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 ------------------------------------------------------------ -........... ------------ -•--------- ----- -------------- •---••-•----------•..... -------------- ..-•- C Description of Soil---------------------------------------------------------------------------------------------------------------------•--------------------.....-•--•----............---- U ----------------•-•---------•--•-•---------------------•---•------------•--------•--•----------•-------------------•----------------------------------------------.....---•-•-------•----••----- W UNature of Rep/pairs or Alterations—Answer when applicable.__�f:`(_`�_�_.!©_I.1____X."r�...5���..1 �a(sak 7 All..................../........ �_•�?c_. ...... ---( ............................/ ✓i ------- i- 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 has been issued by the board of health. 1 g ---- ---..... .. cf -a ----------- ApplicationApproved By ................0 - � ...---...--------------------------------------- ... ------------. p i' ti Application Disapproved for the following reasons- -------------------- ------------------------------- -- ----------------------- ----------- ------------------------ --------------------------------- - .....................................----------- ----..................---- ---------- Permit No- ------------L.-Z ..�_..Y.)�!-....---- ------ Issued --. ........-----------...------------------......Dare Date THE COMMONWEALTH OF MASSACHUSETTS '— BOARD OF HEALTH TOWN OF BARNSTABLE 'IT r#ifira e of CToraptiance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by---------------------- --.... " --'=..... - �"' ..--- —`-.;t 1 ............. ................................................................................................................ ... ----- "uInstaller at ....................................' ...G/...-- -5-( 4 I'" CST 1.-1...1......... .r....... - .-... 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. ........,1 .-....; ...... dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. q DATE ? '.. �� �" .-.. `r------------------------------------------- Inspector THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No..................... FEE.._ --.......... Diopos al Works Tians,trmlion prrmit Permission is hereby granted......Wit. ,n _!...�a-,f? C=_` T, e `�- -- -- - -----------------------------------------------••...........----...... to Construct ( ) "or Repair ( ) an Individual Sewage Disposal. System at No........................................... -----`� ..=--- ? z`• ----.----'t------------__:.------� . Street r as shown on the application for Disposal Works Construction Permit No.__. Dated.......................................... " ~ pt•y �^ S' - .................................................... a hBJlar�li Health DATE-------•----------------�---- -r'�.._�'�.A_...----.......----•---.....---- 0 I-- ( (- FORM 36508 HOBBS 6 WARREN.INC.,PUBLISHERS