HomeMy WebLinkAbout0020 MARCHANT'S MILL ROAD - Health (2) 20 MARCHANT'S MILL ROAD,.HYANNIS
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TOWN OF BARNSTABLE
LOC`.ATION r: r SEWAGE #
VILLAGE I A,#&j � ASSESSOR'S MAP LOT
INSTALLER'S NAME Cz PHONE NO.
SEPTIC TANK CAPACITY %("�9 n C_.c G
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
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BUILDER OR OWNER �+>✓ �� A��9�
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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INSTALLER'S NAME&PHONE NO. d A-, 2
SEPTIC TANK CAPACITY /G
LEACHING FACILITY: (type) (size) i`-1 Z,
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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TOWN OF BARNSTABLE
LOCATION'2-0 le-0 n c�.o �.j yrJ, l ,�cl SEWAGE# i
VILLAGE,1'�P �a/21 ASSESSOR'S MAP&LOT
INSTALLER'S NAME&PHONE NO. °
SEPTIC TANK CAPACITY d b 'y
LEACHING FAciour Y: (type) 6"4' (size)
NO.OF BEDROOMS 4
BUILDER OR OWNER
PERMT'DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
. Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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Commonwealth of Massachusetts o7�& o Oo
v Title 5 Official Inspection Form
aX Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °
C°
wM 20 Marchant Mill Road - houses stem -1of 2 0.1
Property Address ham=
Paul &Stephanie Basta
Owner Owner's Name
information is a
Hyannisport
required for every �
page. City/Town MA 02647 6/6/2017 e,%
State Zip Code Date of Inspection YT
01 Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms # /
on the computer, J c2gg6
use only the tab 1. Inspector:
key to move your
cursor-do not James Ford
use the return
key. Name of Inspector
r° Ford Septic Services, LLC
11 Company Name
P.O. Box 49
Company Address
Osterville MA
City/Town 02655
State Zip Code
508-862-9400 S12482
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 15.600). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Eval ation by the Local Approving Authority
6/7/17
Inspe to's Signature Date
The em 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•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
Lad �
Commonwealth of Massachusetts
Title 5= Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 20 Marchant Mill Road -houses stem -1of 2
Property Address
Paul &Stephanie Basta
Owner Owner's Name
information is
required for every Hyannisport MA 02647
page. City/Town 6/6/2017
State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass"section need to be
replaced or repaired.The system, upon 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):
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Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
20 Marchant Mill Road - houses stem -1of 2
Property Address
Paul &Stephanie Basta
Owner Owner's Name
information is
required for every Hyannisport MA 02647 6/6/2017
page. Cltyrrown State Zi Code
P Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
Pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ _Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a 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 3113
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
4 Title 5 Official Inspection Form
aX Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 20 Marchant Mill Road -houses stem -1of 2
Property Address
Paul &Stephanie Basta
Owner Owner's Name
information is
required for every Hyannisport MA 02647
page. Cltyrrown 6/6/2017
State Zi Code
P 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 manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well*,*.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
i'
i
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than % day flow
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Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
'wM a •`'•• 20 Marchant Mill Road - houses stem -1of 2
Property Address
Paul &Stephanie Basta
Owner Owner's Name
information is
required for every Hyannisport MA 02647
page. City/Town
B. Certification (cont.) 6/6/2017
State Zip Code Date of Inspection
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.
Fordarge systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ . the system is within 200 feet of a tributary to a surface drinking water supply
❑ n 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.
(Sins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
a 20 Marchant Mill Road - houses stem -1 of 2
Property Address
Paul &Stephanie Basta
Owner Owner's Name
information is
required for every Hyannisport MA 02647
page. City/Town 6/6/2017
State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms 3
(design): Number of bedrooms (actual): 3
DESIGN,flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
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Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
I ,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
20 Marchant Mill Road -houses stem -1 of 2
Property Address
Paul & Stephanie Basta
Owner Owner's Name
information is
required for every Hyannisport MA
02647 6/6/2017
page. City/Town State Zi Code
P 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? (Include laundry system inspection
information in this report.) ❑ Yes ® No
I
Laundry system inspected?
❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage(gpd)):
Detail
unavailable
Sump pump?
❑ Yes ® No
Last date of occupancy: unknown
'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:
t5ins-3113
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
20 Marchant Mill Road - houses stem -1 of 2
Property Address
Paul &Stephanie Basta
Owner Owner's Name
information is
required for every Hyannlsport
page. City/Town MA 02647 6/6/2017
State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use:
Date
Other(describe below):
General Information
Pumping Records:
Source of information: pumped in 2016
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�a• 20 Marchant Mill Road- houses stem -1of 2
Property Address
Paul &Stephanie Basta
Owner Owner's Name
information is
required for every Hyannisport
MA 02647 6/6/2017
page. City/Town State
Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
-system installed - unknown date
Were sewage odors detected when arriving at the site?
❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade:
feet
Material of construction:
❑ cast iron ® 40 PVC
❑ other(explain):
Distance from private water supply well or suction line:
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 101,
feet
Material of construction:
® concrete ❑ metal ❑fiberglass 9 El polyethylene El other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes
❑ No
Dimensions: 1500- H-10
Sludge depth: 1
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Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection For
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�A.As••`'•y 20 Marchant Mill Road - houses stem -1of 2
Property Address
Paul &Stephanie Basta
Owner Owner's Name
information is
required for every Hyannisport page. Cltyfrown State Zi 02647 Code 6/6/2017
P Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle 29
Scum thickness 1
Distance from top of scum to top of outlet tee or baffle 6
Distance from bottom of scum to bottom of outlet tee or baffle 10
How were dimensions determined? measure stick
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
There was no sign of leakage. The outlet cover was 10" below
I
Grease Trap (locate on site plan):
Depth below grade: n/a
feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass 9 El 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-3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
aX Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
`�a a,•`''� 2r Marchant Mill Road - houses stem -1of 2
Property Address
Paul &Stephanie Basta
Owner information is Owner's Name
required for every Hyannisport MA 02647 6/6/2017
page. City/Town State
Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
El concrete El metal
❑fiberglass ❑ polyethylene ❑ other(explain):
N/a
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 I(required). s copy attached? El Yes ❑ No
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Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
I
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
a,•°• 20 Marchant Mill Road - houses stem -1 of 2
Property Address
Paul &Stephanie Basta
Owner information is Owner's Name
required for every Hyannisport 02647
page. Cltyrrown Ma e 6/6/2017
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 D-box was normal
Pump Chamber(locate on site plan):
Pumps in working order: El Yes
❑ No"
Alarms in working order: ❑ Yes
❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
15ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
I '
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 2r Marchant Mill Road - houses stem -1of 2
Property Address
Paul &Stephanie Basta
Owner Owner's Name
information is
required for every Hyannisport MA 02647 6/6/2017
page. City/Town State Zi Code P Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields number, dimensions: 20'x40' per info
❑ 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.):
The leach field was dry. There was no sign of failure. A camera was used.
Cesspools (cesspool must be pumped as part of.inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
All 20 Marchant Mill Road - houses stem -1of 2
Property Address
Paul & Stephanie Basta
Owner Owner's Name
information is
required for every Hyannisport
MA 02647 6/6/2017
page. City/Town State
Zip Code Date of Inspection
D. System Information (cont.)
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.):
N/a
15ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
20 Marchant Mill Road-houses stem -1 of 2
Property Address
Paul & Stephanie Basta
Owner Owner's Name
information is
required for every Hyannisport MA 02647
page. City/Town 6/6/2017
State Zip Code Date of Inspection
D. 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
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l5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�•- 20 Marchant Mill Road -houses stem -1 of 2
Property Address
Paul & Stephanie Basta
Owner Owner's Name
information is
required for every Hyannisport MA 02647
page. City/Town 6/6/2017
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: 10'+/-
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:
Topo and water contours map.
❑ Checked with local excavators, installers -(attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
see above
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
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Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
i
Commonwealth of Massachusetts
d Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
`�M a>••` 20 Merchant Mill Road -houses stem -1 of 2
Property Address
Paul &Stephanie Basta
Owner information is Owner's Name
required for every Hyannisport
MA 02647 6/6/2017
page. City/Town State Zi Code
P 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
t5ins-3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
NOTE:
1.) The property line information shown was - -
compiled from available record information.
•
2.) The topographic information w s obtained
from on on the ground survey performed m
071SEP12010.
3.) The datum used is NGVD '29, a fixed mean
sea level datum. -
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LOCATION MAP:
ZONE: ASSESSORS REF.:
1, '[^ i 1 r�H e= RF-1 Mop 266, Parcel 028 _
ea
Area(min.)(min)
20' SF OVERLAY DISTRICT:
o ago Width
F (min)20'
Width(min) 125' - AP-Aquifer Protection Dist,;ct
. 11 '� � r11 °� Setbockr.
Front 30'
. Side 15' FLOOD ZONE:
/ Rear 15' Zone A10(ei 11),B:&C(see plan)
/ /' /'• 7 Community Panel No.
#250001 0008 D _
July 2, 1992
' DIRECTIONS:
From Hyannis-Follow Main Street to the West
l l End Rotary, After Stop sign at Smith Street
/ it .take second right onto Morchants Mill
Rood; House is on the right,120 Legend:
cemr Tree
564'4T160,'W
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4 utany Pale
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--25-- 0—contour
.._.....S.._......underground Utility Line
TITLE Site Plan PREPARED FOR: PREPARED BY.:
Proposed Improvements . Sullivan Engineering,Inc. CapeSury
^I P p Paul &Stephanie Basta
^7 - PO Box 659 -7 Parker Rood
-+ A} 17 South Drive Osterville, MA 02655 Osterville MA 02655 -
/'71 Larchmont NY 70638 Sere,28-33H(SaB)118-961] 1 fe. (508)s20 399 (sae)4zo 399s r,.
—► 20 Marchants Mill Road 4 50nacnPecodhet
Barnstable rHyanni6 art Mass. ft: JOD
20 a a as w
P Dra Oroft: RRL
DATE: SCALE lRewe.. PS Review: RRL
October 14,2010 i w=20'
• - I Prom # 29022 1 Pro}I C618
Reduced
Copy
. Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments -
20 Marchant Mill Road -cottage system -2 of 2
Property Address �'a
PQ
Paul &Stephanie Basta
Owner Owner's Name
information is t/ _0
required for every Hyannisport MA:. 02647 6/6/2017
page. City/Town State Zip Code Date of Inspections
Inspection results must be submitted on this form. Inspection forms may not be altered ?l any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information f�
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not James Ford
use the return Name of Inspector
key.
Ford Septic Services LLC
„a Company Name
P.O. Box 49
Company Address
Osterville MA 02655
City/Town State Zip Code
508-862-9400 S12482
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 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further aluation by the Local Approving Authority
6/7/17
Insprstem
ature Date
Theit
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. r
15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
;r
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
20 Marchant Mill Road -cottage system -2 of 2
Property Address
Paul &Stephanie Basta
Owner Owner's Name
information is required for every Hy p annis ort MA 02647 6/6/2017
page. City/Town State Zip Code Date of Inspection
B. Certification (cont)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 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):
l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
a, 20 Marchant Mill Road -cottage system -2 of 2
Property Address
Paul &Stephanie Basta
Owner Owner's Name
information is required for every Hy p annis ort MA 02647 6/6/2017
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N . ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a 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-3/13 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
20 Marchant Mill Road -cottage system -2 of 2
Property Address
Paul &Stephanie Basta
Owner Owners Name
information is H annis Ort
required for every _y P MA 02647 6/6/2017
page. Cityrrown. 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 manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged-SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/z day flow
(Sins-3/13 Title 5 Official Inspection Form: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
20 Marchant Mill Road -cottage system -2 of 2
Property Address
Paul &Stephanie Basta
Owner Owners Name
information is
required for every Hyannisport MA 02647 6/6/2017
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® 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' or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA)or a mapped Zone 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
'wM 20 Marchant Mill Road -cottage system -2 of 2
Property Address
Paul &Stephanie Basta
Owner Owners Name
information is
required for every Hyannisport MA 02647 6/6/2017
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3- per info Number of bedrooms (actual): 1
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
l5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°°�, a,••''t 20 Marchant Mill Road -cottage system -2 of 2
Property Address
Paul &Stephanie Basta
Owner Owners Name
information is
required for every Hyannisport MA 02647 6/6/2017
page. City/Town 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? (Include laundry system inspection
information in this report.) ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage(gpd)):
Detail:
unavailable
Sump pump?
❑ Yes ® No
Last date of occupancy: unknown
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:
l5ins•3113 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
20 Marchant Mill Road -cottage system -2 of 2
Property Address
Paul &Stephanie Basta
Owner Owners Name
information is
required for every Hyannisport MA 02647 6/6/2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use:
Date
Other(describe below):
General Information
Pumping Records:
Source of information: pumped unknown date
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
20 Marchant Mill Road -cottage system -2 of 2
Property Address
Paul &Stephanie Basta
Owner Owners Name
information is
required for every Hyannisport MA 02647 6/6/2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
stem installed -unknown date
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
Depth below grade: 6
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 - H-10
Sludge depth: 1
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
20 Marchant Mill Road -cottage system -2 of 2
Property Address
Paul &Stephanie Basta
Owner Owners Name
information is
required for every Hyannisport MA 02647
6/2017
page. Cltyrrown 6/
State Zip Code Dateteof—of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 29
Scum thickness 1
Distance from top of scum to top of outlet tee or baffle 6
Distance from bottom of scum to bottom of outlet tee or baffle 10
How were dimensions determined? measure stick
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
There was no sign of leakage. The outlet cover was 6" below
Grease Trap(locate on site plan):
Depth below grade: n/a
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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
'*•.a 20 Marchant Mill Road -cottage system -2 of 2
Property Address
Paul &Stephanie Basta
Owner Owners Name
information is
required for every Hyannisport MA 02647 6/6/2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
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): i
N/a
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-3/13 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
a,•'" 20 Marchant Mill Road -cottage system -2 of 2
Property Address
Paul & Stephanie Basta
Owner Owners Name
information is
required for every Hyannisport MA 02647 6/6/2017
page. City/Town 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 n/a
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
4 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
20 Marchant Mill Road -cottage system 2 of 2
Property Address
Paul &Stephanie Basta
Owner Owners Name
information is
required for every Hyannisport MA 02647 6/6/2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1-600 gal.
❑ 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.):
The pit was dry and in new condition. There was no sign of failure A camera was used
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
20 Marchant Mill Road -cottage system -2 of 2
Property Address
Paul &Stephanie Basta
Owner Owners Name
information is
required for every Hyannisport MA 02647 6/6/2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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.):
N/a
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
20 Marchant Mill Road -cottage system -2 of 2
Property Address
Paul &Stephanie Basta
Owner Owners Name
information is
required for every Hyannisport MA 02647 6/6/2017
page. Cltyrrown State Zip Code Date of Inspection
D. 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
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15ins-3113
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
• ' Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
20 Marchant Mill Road -cottage system -2 of 2
Property Address
Paul &Stephanie Basta
Owner Owners Name
information is
required for every Hyannisport MA 02647
page. City/Town Date of 17
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: 10'+/-
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:
—at e
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health - explain:
Topo and water contours map.
❑ Checked with local excavators, installers -(attach documentation) .
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
see above
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
15ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
v
' G Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
20 Marchant Mill Road -cottage system -2 of 2
Property Address
Paul &Stephanie Basta
Owner Owner's Name
information is H annis Oft
required for every Y P MA 02647 6/6/2017
page. City/Town 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
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
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gage 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
FORM
SUBSURFACE SEWAGE DISPOSAL CAL
SYSTEM INSPECTION
SYSTEM INFORMATION(continued)
property Address: 20 Marchant Mill Rd.
Hyannisport
Owner. Garahan
Date of Inspection: 119 r O f
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including least two permanent reference landmarks or
'
benchmarks.Locate all wells within 100 feet.Locate where ublic water supply enters the building.
on
i •�
1
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r,
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10
t ,}�
\ COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
s
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
RECEIVED
Property Address: 20 Marchant Mill Rd.
Hyannisport, MA ��AR
Owner's Name: Ann Garahan 0 7 Z001
Owner's Address: 1500 Wor -ester Rd
-
TAB
OF BARNSTABLE
HEALTH DEPT.
Date of Inspection: ,u-- z v /
Name of Inspector:(please print) Wi 1 1 i am E_ . Robinson Sr.
Company Name: William E. Robinson Septic Service
Mailing Address: P 0 Box 1089
Centerville, MA
Telephone Number: (5 0 8) 7 7 5—8 7 7 6
I
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:
I I/Passes /
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: J lZ Date: 4�-V-3—DJ
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heaith,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
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
}
Page 2 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued).
Property Address: 20 Marchant Mill Rd
Hyannisport
Owner: Garahan
Date of Inspection: -d2 3-O
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. Sys m Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repa ed.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Ans er yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please
expl
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
uns d,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the
exis ing tank is replaced with a complying septic tank as approved by the Board of Health.
*A etal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
in icating that the tank is less than 20 years old is available.
explain:
Observation of sewage backup or break out or high static water level in the distribution box due to-broken or
ot structed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
ar proval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
p s inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Page 3 of l 1
I'
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 20 Marchant Mill Rd.
Hyannisport
Owner: Garahan
Date of Inspection: A—;L 3-a /
C. urther 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 fail g 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
ystem 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. yytem will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
syst 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
urface 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
rivate water supply well**.Method used to determine distance
*This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
acteria and volatile organic compounds indicates that the well is free from pollution from that facility and
e presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
ilure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 20 Marchant Mill Rd.
Hyannisport
Owner: Garahan
Date of Inspection: IL-a-3—o I
D. System Failure Criteria applicable to all systems:.
You must indicate"yes'.'or."no"to each of the following for all inspections:
s No
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_ Liquid depth in cesspool is less than 6"below invert or available volume is less than %z day flow
_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
Any portion of the SAS,cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
arge Systems:
To b considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You ust indicate either"yes"or"no"to each of the following:
(The ]lowing criteria apply to large systems in addition to the criteria above)
yes o
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well 4
If you I eve answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes" Section D above the large system has failed.The owner or operator of any large system considered a
signifii ant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.30 The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 20 Marchant Mill Rd.
Hyannisport
Owner: Garahan
Date of Inspection: , ,�-3—0 r
Check if the following have been done You must indicate"yes"or"no"as to each of the following:
Yes o
Pumping information was provided by the owner,occupant,or Board of Health
Were any of the system components pumped out in the previous two weeks?
Z/Has the system received normal flows in the previous two week period?
'V 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
t-/_ Was the site inspected for signs of break out?
Were all system components,excluding the SAS,located on site
t/ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
'of _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:
Yes no
Existing information.For example,a plan at the Board of Health.
t/ 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)]
4
5
Page 6 of l l
OFFICIAL INSPECTION FORM.-NOT FOR VOLUNTARY ASSESSMENTS �.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 20 Marchant Mill Rd.
Hyannisport
Owner: Garahan
Date of Inspection: ;I, ^.A 3--o/
FLOW CONDITIONS
RESIDENTIAL C o r/,o C °Z'
Number,of bedrooms(design): —7 Number of bedrooms(actual):s3 5
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): `1 o �` �°
Number of current residents: () 3 Q
Does residence have a garbage grinder(yes or no):"
Is laundry on a separate sewage system(yes or no)A 6 [if yes separate inspection required]
Laundry system inspected(yes or no): &o
Seasonal use: (yes or no):�3
Water meter readings,if available(last 2 years usage(gpd)): 2000 3 0 0,7 5 0 gal.
Sump pump(yes or no):A.v 1999 370, 500 gal.
Last date of occupancy: A,1A
CO MERCIAL/INDUSTRIAL
Type establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis o design flow(seats/persons/sgft,etc.):
Grease Tap present(yes or no):
Industri il waste holding tank present(yes or no):_
Non-sa titary waste discharged to the Title 5 system(yes or no):_
Water i ieter readings,if available:
Last date of occupancy/use:
OTHL(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no): 46 .
If yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping:
TYP F SYSTEM
_ eptic tank,distribution box,soil absorption system
_Single cesspool
Overflow cesspool
Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank _Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,dat2'nstalled(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):,G C)
6
Page 7 of I 1
i.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 20 Marchant Mill Rd.
yannispor
Owner• ara an
Date of Inspection: --;L --a l
B LDING SEWER(locate on site plan)
Dep below grade:
Mate ials of construction:_cast iron _40 PVC_other(explain):
Dis nce from private water supply well or suction line:
Co ents(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: S/(locate_on site plan)
Depth below grade:
Material of construction:L,&ncrete_metal_fiberglass_polyethylene
—other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate) 7'� , ,, I-P 'I G` T
Dimensions: G Z " 10,4
Sludge depth: 3—,-�
Distance from top of sludge to bottom of outlet tee or baffle:-�
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined: O AL;;'w
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of.leakage,etc.):
�1� .s � N. •o/a c !� Igo v s G� I S�-{>
GRE SE TRAP:_(locate on site plan)
Depth below grade:_
Mate al of construction:_concrete_metal_fiberglass__polyethylene_other
(expl ):
Dime sions:
Scu thickness:
Dis ce from top of scum to top of outlet tee or baffle:
Dis nce from bottom of scum to bottom of outlet tee or baffle:
Dat of last pumping:
Co ents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as r lated to outlet invert,evidence of leakage,etc.):
7
Page 8 of 1 l '
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 20 Marchant Mill Rd.
Hyannisl2ort
Owner: Garahan
Date of Inspection:
T HT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Dep h below grade:
Mat rial of construction: concrete metal fiberglass_polyethylene other(explain):
Di ensions:
Cap city: gallons
Des gn Flow: gallons/day
Al present(yes or no):
Al level: Alarm in working order(yes or no):
D to of last pumping:
C ents(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 to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.): l
c /xJOUsv Ga �.
PU P CHAMBER: (locate on site plan)
Pum sin working order(yes or no):
Al s in working order(yes or no):
Co ents(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of I 1
4 _
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 20 Marchant Mill Rd.
Hyannisport
Owner: Garahan
Date of Inspection: ! ";r 3—O
SOIL ABSORPTION SYSTEM(SAS):J-14locate on site plan,excavation not required)
If SAS not located explain why:
.ty
Type
/ leaching pits,number: / 4o c� $✓o > �v c L
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
_leaching fields,number,dimensions: A
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.): y
CESSPO LS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and onfiguration:
Depth—top o liquid to inlet invert:
Depth of solid layer:
Depth of scu layer:
Dimensions o cesspool:
Materials of c nstruction:
Indication of oundwater inflow(yes or no):
Comments(n a condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materials f construction:
Dimensi0 s:
Depth of
m solids:
Comen s(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
vvl
Page 10 of 11 '
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS _
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 20 Marchant Mill Rd.
Hyannisport
Owner: Garahan
Date of Inspection: 1. J&-0/
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.
J
> - aX
r
1
10
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 20 Marchant Mill Rd.
Hyannisport
Owner: Garahan
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 0 feet
Please indicate(check)all methods used to determine the high ground water elevation:
9btained from system design plans on record-If checked,date of design plan reviewed:
VI-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 y u established the high ground water elevation:
a k_ o y— t✓a i d Z. di, r� 6 !d//eazx
11 II
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
De artment of R�cEO
Environmental Protection FEB s 1996
William F.Weld ' `
Govemor
Trudy Coxe
Secretary,EOEA
David B.Struhs ®1
Comminioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
�vJiC:KAh�/�i'lI RZ, PART A
CERTIFICATION
Property Address: Address of Owner. �D�►�
Date of Inspection: s`S (If different)
Name of Inspector: W.E. Robinson Sr.
Company Name, Address and Telephone Number: W.E. Robinson Septic Service
P.O. Box 1089
Centerville MA
CERTIFICATION STATEMENT 77�7
1 certify that I have personally inspected the sewage dispos�l sPstert� t this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
'/Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: L s Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. If.the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C, or D:
A] SYSTE PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
T
re system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
ection.
Indicnot determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain wiry not)
he septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is
mminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
pproved by the Board of Health.
(revised 8/15/95) 1
One Winter Street a Boston,Massachusetts 02108 a FAX(617)556-1049 a ,Telephone(617)292-SM
i'Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
02 o MAr�n t 14 �� &Allyn t7 6 d"i`-
Property Address:
Owner: ilo h h j(-'Arr.,4hA1)
Date of Inspection:
B] SYSTE' ONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
_ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C) FURTHER ALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Condi ions exist which require further evaluation"by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTE WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHIC WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYS WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE S TEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
_ T e system has a septic tank and soil absorption system and is within 100 feet to a surface waiei supply or tributary to a
s rface water supply.
_ T e system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
_ T e system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
_ T e system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
upply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is
e from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
pp
D] SYSTEM FAILS:
I have determin that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determi ation is identified below:.The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Back of sewage into facility or system component due to an overloaded or dogged SAS or cesspool
_ Discharg or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged.SAS or
cesspool.
(revised 8/15/95)< 2 y
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:o2
Owner: <-jahvl
Date of Inspection: _ 5
D)SYSTE FAILS(continued):
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of.a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E]LARGE YSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The de ign flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety
and the environment because one or more of the following conditions exist:
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
t e system is located in.a nitrogen sensitive area(Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a
p blic water supply well)
The owner or operat r of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 8/15/195) 3
L 1 1 1T
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: _ 2R 4 h 4 yr
Owner: ash o AP
Date of Inspection: / -;LY -Cj Q
Check if the following have been done:
14umping information was requested of the owner, occupant, and Board of Health.
L/None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
'' //during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
ZAs built plans have been obtained and examined. Note if they are not available with N/A.
l/TThe facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow
_J/he site was inspected for signs of breakout.
II system components, excluding the Sdil Absorption System, have been located on the site.
_t a septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
_J/he size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
_t he facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 8/15/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION .
Property Address:
Owner: cJd h/t
Date of Inspection: l
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 22 O gallons
Number of bedrooms:
Number of current residents: D
Garbage grinder(yes or no):A-.,
Laundry connected to system (yes or no):�
Seasonal use (yes or no):—,K
Water meter readings, if available:
Last date of occupancy: / —2-s
COMMERCIAUINDUSTRIAL:
Type of establishment:
Design flow:_,-gallons/day
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:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS an source of information:
.dt
System pump4d as part of inspection: (yes or no)
If yes, volume pumped. gallons
Reason for pumping:
TYP/OF EM
c tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Other(explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information: ;;Ld A"' tr►2
Sewage odors detected when arriving at the site: (yes or no)
i
(revised 8/15/95) S
,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: v-'e h�► ��9rr.9/.4
Date of Inspection: _�S-7,6
SEPTIC TANK:_✓
(locate on site plan)
i !
Depth below grade:
Material of construction: oncrrete _metal _FRP_other(explain)
O
Dimensions:
Sludge depth: to,
Distance from top of sludge to bottom of outlet tee or baffle:;L-
Scum thickness: / 6
Distance from top of scum to top of outlet tee or baffler_ ,
Distance from bottom of scum to bottom of outlet tee or baffle:_
Comments:
(recommendation for pumping, conditio feet and ottlet tees or baffles; depth of liquid level in relation 4o outlet in rt, structural
integrity, evidence of leakage, etc.) °'� I L� Y
GREASE T P:_
(locate on site Ian)
Depth below gra
Material of constr ion: _concrete _metal _FRP—other(explain)
Dimensions:
Scum thickness
Distance from top f scum to top of outlet tee or baffle:
Distance from bo om of 5rurn t� hotlOm Of OLMet tee or baffle:
Comments:
(recommendation fo pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.,
(revised 8/15/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
` SYSTEM INFORMATION (continued)
Property Address: /)�/9/•��9���'1'�� /dam o�f�i4/I/�lS j✓o�'j""
Owner:
Date of Inspection:
TIGHT R HOLDING TANK:_
(locate on ite plan)
Depth belo grade:
Material of c nstruction: _concrete _metal _FRP—other(explain)
Dimensions:
Capacity: gallons
Design flow- Rallons/day
Alarm leve
Comments:
(condition of in et tee,.condition of alarm and float switches, etc.)
i
DISTRIBUTION B X:_
(locate on site pla )
Depth of liquid I el above outlet invert:
Comments:
(note if level a d distributiun is equal, evidence of solids carr,o•:cr, evidence of leakage into or out of box, etc.)
PUMP CHAMBE
(locate on site pl n)
Pumps in workin order.(yes or no)
Comments:
(note condition of ump chamber, condition of pumps and appurtenances, etc.)
(revised 8/15/95) 7
r Y
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: cJ`G h r7 r�rgRA�3/rA r7
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):V
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:_
leaching chambers, number: 5
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Comments: (note condition of soil, signs of h draulic fa' ure, level of pondin , condition of vegetation etc.)
CESSPOOLS• _
(locate on sit Ian)
Number and confi urati0n:
Depth-top of liqui to inlet invert:
Depth of solids laye
Depth of Scum layer:
Dimensions of cessp I:
Materials of constructi n:
Indication of groundw tei:
inflow (cess ool must be pumped as part of inspection)
Comments: (note c4 ition 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 conditiorl4soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 8/15/95) 8
VN O
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: D �/�rG�.9✓/ Nei// I°� �`�f �nis��'r
Owner. v`oh�? G'•9�"//f/t�9r7
Date of Inspection: —91
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
l)
gay 51aw %
DoW �v
3D
DEPTH TO GROUNDWATER
Depth to groundwater:_L_ !
method of determination or approximation: 1 5144 a ! S 17 5
(revised 8/15/95) 9