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HomeMy WebLinkAbout1160 PHINNEY'S LANE - HYANNIS CONDOS 1160}PHINNEY_ 'S LANE77Wi6oW Terrace Hyannis µ . Commonwealth of Massachusetts Title 5 Official Inspection Form 1; 1' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1160 Phinneys Ln, BLDG 1 - Property Address - Arbor Terrace Owner Owner's Name information is required for every Hyannis MA 02601 5-7-12 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information 11►r►t,►,,,,-,- - --- r�rr++t++ on the computer, �r e��N D�k4S use only the tab 4�4�` t`''� key to move your 1. Ins ector: V-5q ti p °• jAMES cursor-do not James DSears use the returna ,�__ i , ,^ '` key. Name of Inspector ; Capewide Enterprises, LLC ��':cFiT t,~r�°`o� rab Company Name — -- i�� ttt-- ' ,r `1 �__. 153 Commercial St. Company Address Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 Telephone Number License Number A 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 16.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 5-7-12 I ector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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. � I t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1160 Phinneys Ln, BLDG 1 Property Address Arbor Terrace Owner Owner's Name information is required for every Hyannis MA 02601 5-7-12 page. Cityrrown 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): l5ins•11/10 1 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1160 Phinneys Ln, BLDG 1 Property Address Arbor Terrace Owner Owner's Name information is required for every Hyannis MA 02601 5-7-12 page. Cityrrown 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 r Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1160 Phinneys Ln, BLDG 1 Property Address Arbor Terrace Owner Owner's Name information is required for every Hyannis MA 02601 5-7-12 page. City/Town 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'/2 day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 r c Commonwealth of Massachusetts _. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments f; 1160 Phinneys Ln, BLDG 1 Property Address Arbor Terrace Owner Owner's Name information is required for every Hyannis MA 02601 5-7-12 page. Citylrown 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•11/10 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 1160 Phinneys Ln, BLDG 1 Property Address Arbor Terrace Owner Owner's Name information is required for every Hyannis MA 02601 5-7-12 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): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 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 u 1160 Phinneys Ln, BLDG 1 Property Address Arbor Terrace Owner Owner's Name information is required for every Hyannis _ MA 02601 5-7-12 page. CitylTown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes El No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form f' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1160 Phinneys Ln, BLDG 1 Property Address Arbor Terrace Owner Owner's Name information is required for every Hyannis MA 02601 5-7-12 page. Cityrrown 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: 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ la Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1160 Phinneys Ln, BLDG 1 Property Address Arbor Terrace Owner Owner's Name information is required for every Hyannis MA 02601 5-7-12 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: Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): l 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: 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: Sludge depth: Lt5m. 1110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Io Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1160 Phinneys Ln, BLDG 1 Property Address Arbor Terrace Owner Owner's Name information is required for every Hyannis MA 02601 5-7-12 page. Citylrown 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 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? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 c Commonwealth of Massachusetts Title 5 Official Inspection Form I o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 1160 Phinneys Ln, BLDG 1 Property Address Arbor Terrace Owner Owner's Name information is required for every Hyannis MA 02601 5-7-12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 1160 Phinneys Ln, BLDG 1 Property Address Arbor Terrace Owner Owner's Name information is required for every Hyannis MA 02601 5-7-12 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 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ 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 c Commonwealth of Massachusetts - Title 5 Official Inspection Form r~' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1160 Phinneys Ln, BLDG 1 Property Address Arbor Terrace owner Owner's Name information is required for every Hyannis MA 02601 5-7-12 _ page. City/Town State Zip Code 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: ❑ 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.): 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 1i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4� 1160 Phinneys Ln, BLDG 1 Property Address Arbor Terrace Owner Owner's Name information is required for every Hyannis MA 02601 5-7-12 page. Cityfrown 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.): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1160 Phinneys Ln, BLDG 1 Property Address Arbor Terrace Owner Owner's Name information is required for every Hyannis MA 02601 5-7-12 page. Cityrrown 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 t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Rap ` Page of � It44111 'own of Barnstable Geographic Information System € Map s Z� In -A a wit tom" • 77 { -S S' 20 et 16'Fe -, a x , . - - •. #`a�3dat#!S .`3"k'S�3•:�.-�e:€ .Svtrs ATD�rJ�6s4s saaozs.o Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1160 Phinneys Ln, BLDG 1 Property Address Arbor Terrace Owner Owner's Name information is required for every Hyannis MA 02601 5-7-12 page. City/Town 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: 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: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form I a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4� 1160 Phinneys Ln, BLDG 1 Property Address Arbor Terrace Owner Owner's Name information is required for every Hyannis annis MA 02601 5-7-12 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 r _ . Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 1160 Phinneys lane Bldg.#1 Property Address Arbor Terrace Condominiums Owner O -ter's Name information is #h il l s required for Ma. 02632 1/27/2009 every page. City Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms the S I-> �3 2/I i computer, r,use 1.1 Inspector: only the tab key to move your Robert Paolini '-cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name +� P.O.Box 763 Company Address Centerville Ma. 20632 City/Town State Zip Code (508)428-4028 S14454 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 Evaluation by the Local Approving Authority 1/27/2009 Inspector's Signatur 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. (� Z16 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° M 1160 Phinneys lane Bldg.#1 Property Address Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma. 02632 1/27/2009 every 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: ® 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: The septic system is in proper working order at the present time. 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): j t5ins 09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 2 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 1160 Phinneys lane Bldg.#1 Property Address Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma. 02632 1/27/2009 every page. City/Town 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 3 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 1160 Phinneys lane Bldg.#1 Property Address Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma. 02632 1/27/2009 every page. City/Town 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 r 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 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 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 El E.- due to an overloaded or clogged SAS or cesspool El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 4 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1160 Phinneys lane Bldg.#1 iG M Property Address Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma. 02632 1/27/2009 every 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. 1 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 11 of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 5 �. Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for-Voluntary Assessments wM 1160 Phinneys lane Bldg.#1 Property Address Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma. 02632 1/27/2009 every 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? ` El ® 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? ® ElWas 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): $ Number of bedrooms (actual). 8 DESIGN flow based on 310 CMR 15.203.(for example: 110 gpd x#of bedrooms): 880 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 6 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 1160 Phinneys lane Bldg.#1 Property Address Arbor Terrace Condominiums t Owner Owner's Name information is required for Centerville Ma. 02632 1/27/2009 every page. City/Town State Zip Code Date of Inspection D. System Information Description: The septic system consists of a 2000 gallon septic tank,Distribution Box and two 1000 gallon Leaching Pits. Number of current residents: unknown Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readin s;if available last 2 ears usage d separate"meters 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 1/27/2009 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° M 1160 Phinneys lane Bldg.#1 ' Property Address Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma. 02632 1/27/2009 every 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: Capewide Enterprises,LLC. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Tank pumped 10/22/2008 for maintenance 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 8 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 1160 Phinneys lane Bldg.#1 Property Address . Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma. 02632 1/27/2009 every 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: 1998 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 18" Depth below grade: feet Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 1 + fee et Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the building vents. Septic Tank (locate on site plan): Depth below grade: 2' Cover to grade 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: 2000 gallons 511 Sludge depth: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 9 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1160 Phinneys lane Bldg.#1 Property Address Arbor Terrace Condominiums Owner Owner's Name information is Centerville Ma. 02632 1/27/2009 required for every 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 30" Scum thickness 1 711 Distance from top of scum to top of outlet tee or baffle 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.): pump septic tank yearly.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears to be structurally sound. 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 10 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form , Not for Voluntary Assessments c,M 1160 Phinneys lane Bldg.#1 Property Address Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma. 02632 1/27/2009 every 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): 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 11 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1160 Phinneys lane Bldg.#1 Property Address Arbor Terrace Condominiums Owner Owner's Name information is Centerville Ma. 02632 1/27/2009 required for every 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 No Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box is Ievel.Box has two outlet Iaterals.Speed levelers should be installed to equal distribution.No evidence of solids carryover.No evidence of leakage into or out of box. 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.): 7 Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 12 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments CGM , 1160 Phinneys lane Bldg.#1 - Property Address Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma. 02632 1/27/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) , Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching,trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ . innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic fa'ilure,.level of ponding, damp soil, condition of vegetation, etc.): Sandy dry soil.No signs of hydraulic failure.Pit#1 water level was 9"to invert and pit#2 only had 6" of water on bottom With stain line 52" below invert. { 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM 1160 Phinne s lane Bld .#1 Y 9 Property Address Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma. 02632 1/27/2009 every 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.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 14 y. Map Page 1 of 2 Town of Barnstable Geographic Information System s Parcel Viewer Custom MapIF Abutters Map Size ONE Zoom Outfl.EjMjMjMjIn I 3 - t 4 : • I � rINI f . 1,111-1 {ram. K f ,..� "'IR r i 9 � i• d i a 0 2� ke e t Set Scale 1 20 I Aerial Photos I MAP DISCLAIMER I (`nrnirinh4 9f1l1F_9MA T--of Q-f.hln RAC All r;nhfo rcecn., hq-://wwXr.town.bAmstable.maxis/arelft"s;/ pgeoapp/map.aspx?proper yTD=2730890OA&... 1/27/2009 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 1160 Phinneys lane Bldg.#1 Property Address Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma. 02632 1/27/2009 every page. City[Town 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: Bottom of LP 60' 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: As-Built Card ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-000-01 plate#2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 1160 Phinneys lane Bldg.#1 Property Address Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma. 02632 1/27/2009 every 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 J S r l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 1 w'V5"'r' r p" L't,Rt,ISTABLE Z_J-N JAIN 10 PrI 1: 19 DATE 1219105 UNVISION PROPERTY ADDRESS 1160 %h.inneyz Lane 'In-it 1 Na z 02601 On the above date, the septic system at the address above was Inspected. This system consists of the following: 7., 1-'2000 ga eion tank., 2., 1- D izi-a ig4t.ion L3ox.' 2- 1000 ga.ieon 2each.ing 12.itz Based on Inspection, I certify the following conditions: 7h.iz .ins a 7.i'Ue Five Ze-12t.ic zyz.tem (78Code) Se12t.ic bybtenr. .ib .iri 12,TO let Wo2k.ing ozde2 at the /laezent time., SIGNATURE e' n Name: Robert A. Paollnl Company: Joseph P. Macomber & Son Inc . Address: P. 0. Box 66 Centerville, Mass 02632 Phone: 508-715.3338 or. 508-776-6412 �\ JOSEPH P. MACOMBER. & SON;: INC. . Tanks-Cesspools-Leachfields Pumped &:Installed Town Sewer Connections P.O. Box 66 Centerville, MA.026.32c-0066 775-3338 . 775.6413- ' • COMMONWEALTH OF SSACHUSETTS omcunw 0mcE OF•ENvmoNmENrAL AFFAIRS DEPARTNmNT OF EN viRONMI?N rAL FROTSCTIm MZE 5 OFFICIAL INSPECnON FORM—NOT FOR.VOLUNTARY ASSES~SME?M SUBoS 3tFACE SEWAGE DMOSAL SYSTEM FORM PA►Rr A GERM,CERM,WATION propel Address: 116 0 %h i yanni.6 Na ovmesl���y�:�,42 so2 I-v_a.arzro Canrin Owmes D►afe.afItar 1219105 maw .:.Robert A Paolini CNauet T_P=Ma bomber & Son Inc. &b fmgAddres= Rnx• fif; Centerville e MA 02632 Tdq&wNuibw.508-775-3338 CERTIFICATION STATEMM 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 onmy training and experience in the I nWer function and maintenance of on site smage disposal systems.I am a DtEP gWoved system WspecW Aso t to Seethm I&M of T#k 5{3I0 CMR 15:@M— The system: XXXPasses Conditionally Passes Needs Furdur Hvghwhon by the Local Akxvving.Audmdty • Iaspector's Signature: Dtaite: v65 The system inspector shall submit a copy of this inspection report to the Ap}a+aeing Aud ority(Board of Health or Dlp)vritMn 3tl days of completing this inspection.If the system is a shared system or has a design flow of 10,OW gpd or Beater,the inspector and dw ystem owner shall.submit the report to the appropiate regicxW office of the DM The original shculd be sent to the system owner and copies seat to the buyer,if appficwW and the appmving autbotlty_ Notes and C msents rcpoatoMy domes coudidens at do thaegfUspedluumd mubr do equdideas of use at Ad alp This erection aloes not address iraw dw..system wM pnfertn ra an fob=uj#r the same or d Title 5Inspection Form' 6/IN2000 page t r Page 2 of 11 OFFICIAL INSPECTION:.FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FUTtiI i4 PART A CERTIFICATION(continued) Property Address: 1160 %h.inney.c Lane /Init 1 Elyann.iz Owner:,42&oa 7e2aace ConZ6 Date of Inspection: 12/9 TO 5 Inspection Summary: Check A,B,C,D or E/ALWA-Y�S complete atl of Section:D A. System Passes: qES NO I have not found any information which indibates'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: Seft.ic Zy,6tem .i-s .in /22o/2ea woak.ing oaden at the Paezent Lime., B. System Conditionally Passes: n o One or more system components.as described in the"Conditional Pass":section need tote replaced:or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not.determined(Y,N,ND)in the for the following statements.If"not determined"please explain. no The septic tank is metal and,over20 years old*.or the septiF tank(whether metal or:not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank,as approved by.the.Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: no Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection.if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: n o 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 pipes)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION:FORM PART A CERTIFICATION(continued) Property Address: 7160 &h 'nn Lan l t 1 yann.�.5 �17a Owner: 42Qoa e22ace Coado.i Date of Inspection: 1219105 C. Further Evaluation is Required by the Board of Health: n° 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(l)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: no Cesspool or privy is within 50 feet of a surface water aoCesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a mariner that protects the public health,safety and environment: no The system has aseptic 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. n 0° The-system has a.septic tank and SAS and the:SAS is within a Zone 1 of a public water supply. n o The system has a septic tank and.SAS and:the SAS is within 50 feet of a private water supply well. n o 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 visua-0 . **This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5.ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: c 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR;VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 7160 Phi inneyz Lane llnct Kyanad.z Owner:A&9o2. 7 &,,zace Condo Date of Inspection: 1219105 D. System Failure Criteria applicable to all systems: You must indicate"yes".or"no"to.each ofthe.following:for all inspections: Yes No _ X Backup of sewage into facility or system component due to overloaded or.clogged SAS.or.cesspool _ X Discharge:or ponding of effluent to the surface of the:ground or surface waters due to an loverloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than May flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s)•Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or priv water supply: y is within 100 feet of a surface water supply.or tributary to a surface X Any portion of a cesspool or privy is within a Zone I.,of a..public well.. X Any portion of a cesspool or privy is within.50 feet of a private water supply well. X Any portion of a cesspool or-privy is less than 100 feet but greater.than 50 feet from a private water supply well with no acceptable water quality.analysis..[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 ford.] N0 (Yes/No)The system fails.I have determined that one or more�f.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 s gPd• ystem the system must serve,a facility with a design flow of 1,01000 gpd to 15,000 You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes _ the system is within 400 feet of a surface drinking water supply _ X the system is within 200 feet of a tributary to a surface drinking water.supply X 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. 4 Page 5of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1160 P h.inn.eyz Lane 11nit 1 llyann.iz Owner: 4'ko ¢ .te)t zace Condos Date of Inspection: 1219105 Check if the following have been done.You must indicate"yes"or"no"as-to each.ofthe.following: Yes No _ X Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal.flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of th[ss inspection? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS;located on site,?. X _ Were the septic tank manholes uncovered;opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and..depth of scum? 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 X Existing information.For example,a plan at 4'e Board of.Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1160 %hinneyz Lane 11n.ij-1 1 ✓luanniz ('lays. Owner: .1/tP,02 7eaaace Condo.6 Date of Inspection: 1219105 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): .8 Number of bedrooms(actual): 8 DESIGN flow based on 310 CI1M 15.203(for example: 110 gpd x#of bedrooms): B 8 0 Number of current residents: unknown Does residence have a garbage grinder(yes or no): no Is laundry on a separate sewage system(yes or no): no [if yes separate inspection required] Laundry system inspected(yes or no): n o Seasonal use:(yes or no):� N/A Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): no Last date of occupancy: 122 e 6 e n t COMMERCIALd USTRIALN�. Type of estab�hiont: Design flow( `ased on 310 CMR 15.203): gpd Basis of desio-11ow(seats/persons/sgft,etc): Grease trap present(yes or no):T Industrial waste holding tank.present(yes or no): Non-sanitary waste discharged to the Title 5 system-(yes or no): Water meter readings, if available: Last date of occupancy/use: . OTHER(describe): GENERAL INFORMATION Pumping Records yea2 fey Source of information: Was system pumped as part of the inspection(yes or no): a o If yes,volume pumped:_gallons--How was quantity pumped determined? _ Reason for pumping: TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system . _Single cesspool _Overflow cesspool —ivy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: 4117198 Were sewage odors detected when arriving at the site(yes or no): 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM'INFORMATION(continued) Property Address: 1160 %h.iane e Lane lln it 1 yann.iz owner: lla&oa teaaace Condos Date of Inspection: 721Y75 BUILDING SEWER(locate on site plan) Depth below grade: 18" Materials of construction:_cast iron X 40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): ao.intz aae t.ight.- Vented thorough 9,ai2d.ing SEPTIC TANK:y ee-locate on site.plan) 2000 ga 2.2 o ns Depth below grade: at ga a d e Material of construction:7concrete_metal_fiberglass_polyethylene --Other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 1 2'X 5 ' 8"X 6' 6" Sludge depth: a c e Distance from top of sludge to bottom of outlet tee.or baffle: t as ce Scum thickness: t a a c e Distance from top of scum to top of outlet tee or baffle:t a a c e Distance from bottom of scum to bottom of outlet tee or baffle: to a c e How were dimensions determined: me a u z a e d Comments.(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid.levels as related to outlet.invert,evidence of.leakage,etc.): umI2 tank eaa.2ey., Inlet outpof I_vn.t nno ;n aPa4v_ Tntzk ztauctuAaZZyz .noun GREASE TRAP: n glocate on site plan) Depth below grade:_ Material of construction:._concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Gaease tal2a .is not Rae.6emt Page 8 of 1 I OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION1 FORM PARS'C SYSTEM INFORMATION(continued) Property Address: I 1 d 0 10h inney-s Lane lln' it 1 H annT . Owner: 429o2 7ea2ace on ors Date of Inspection: TIGHT or H • NO OLDING 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:_ Qallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes.or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): 7i ht on hoid.ing tanks aae not 12aezent. DISTRIBUTION BOX: 0 (if present must be opened)(locate on site plan) . Depth of liquid level above outlet invert: 0 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): Box iad .2evei.- ,,Kaz 3 a2tezaiz., No zotid caazy ove2 oa• .leakage .in oa ou o ox.1 PUMP CHAMBER: no (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Pump cham9e2 .is not /2ae6ent ,4 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1760 Ph.inneyz Lane ' Hyaan.i s Na Owner:.Aa&oa Teaaace Condos .Date of Inspection: 1210105 SOIL ABSORPTION SYSTEM(SAS): '(locate on site plan,excavation not required) If SAS not located explain why: Located zee /gage 10 Type X leaching pits,number: 2 leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): �. Loamy to medium sand.- No z ianz o- la.iivae oa Pond.ing.11 o.iiz aae d/zu Vegetation 1z no/tmnD CESSPOOLS: no (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes br no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Ce6,612oo2.s aite not paesent PRIVY: n.n (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.): l 2•iuy .i,5 not 12ae6ent 9 Page 10 of 11 EIAL INSPE+CTION'FORK,NOT FOR VOLUNTARY ASSESSMENTS SVBSU7ACE SEWAG ;DI3P.OSAL SYSTEM INSPECTION FORM !-' PART C SYSTEM INFORMATION(continued) Property Address: 116 0 P h i n n ezL n e 11ni t 1 yanntz Owner: R2go/L te29%05 Condo Date of Inspection: KETCH OF SEWAGE DISPOSAL SYSTEM Jr de 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 • �!tp t�7 ' Co- • � � ''��/- Ill �i: t • 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ON.FORM ASSESSMENTS . ``. SUBSURFACE SEWAGE DISPOSAL SYSTEM PART C SYSTEM INFORMATION(continued) Property Address: .116 0 P h.inne z Lane Unit. l gannzz Owner:Aagoa 7eaaaca Condos Date of Inspection: 9/0 5 w SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground.water feet Please indicate(check)all methods used to determine the high ground water elevation: -N 0 Obtained from system design plans on record-If checked,date of design plan reviewed: u e-3 Observed site(abutting property/observation hole within 150 feet of SAS) h g"Checked with local-Board of Health-explain:z a a % n i n n n d n o Checked:with local excavators,installers-(attach documentation) t ens®ccessedUSGSdatabase=explainAttR�to�n: tlaanbtaBQe. ma. ub You must describe how you established the high ground water elevation: llzed. : Cape Cod Comm.is.ion idatea Segie1995toua.s And %uBQie Glatea Su�/s2y �le�Q head aotectlo•n aaea� ma Oat ea aezouace s ozlice ca a co- r-amm.i s.ion Top V Leaching Pit l�' ;eet GroundwateiFeet Below Bottom:of Pit High Groundwater Ad}ustment 1.8 ft per Frimpter Mothod Therefore,the vertical.separation distance between the bottom of the leaching pit and the adjusted groundwater table is r feet. . 11 ' 1 • �rnt*��,mr.r••� -.�t„�.,�.,....�.�. .ro BOARD OF U$A*LT11 SUBSURFACR BEWAUR DISPOSA1r SYSTEM INSPECTION FORM - DART D•r CERTIFICATION «•TtY •,S.-T,11{•,Z7'*•Mmm•RItrIT7.�1f�.�• �!'�8•.TR -lrypt oR PRINT CLEARLY- PItOPRIiTY IN.SPI•!C"D STREET ADDRESS 1.160 %hinneyz Lane Unit I ASSESSORS MAP, BLOSK AND 'PARCEL #� A/19oa tea2ace Condo.,S OWNER's NAME PART'*D CRRMUCATZON Rotes t P.a.okLn•i ' NAME -OF INSPECTOR . COMPANY NAME o e . 1 . I7acoM8e ' Son Inc Box 66 Cen�eav i C fe 17a�b' 026.32 ' COMPANY ADDRESS Town-or City. BtaL� LiP . C strQO�' COMPANY TELEPHONE ( 508. Y 7.5 - 3338 FAX (' 508)190 � f 578 CER'r-I'FICATION. STATEMENT r ,t eWa e 'dig osal. system at ' 'all .ins�peated .the Q g p i• certify that.• I have person Y this address and that t1id information reported .is true,. a.aottra-te•, acid omplete as of the time ..Of�inspeetion..• The in.9pectio.'n was per•Fo:rmed and any recommendations regarding upgrade, .ma•intenn.nee ,' and icepalr .afie consistent with my trainilig and exp.q*rience in the proper function and maintenance of on- site sewage dtsposai ,t . Check one: , rXXXSysteo PAS D , The inspection whic.M •I have conducted has .,not found any information . which indicates that the system- tails to '.adequately. protect .publiv health or the envi.ropment as defined in. .310 CMR. IC30.3-, Any failure criteria Oot evaluated are as stated in the FAILURE CRITERIA section o:f this• form. System FAILED* the sstem hat ails The inspection which I �RvendothQ en ranment�intacaordance withfTitletQ protect the public health t� 61 319 CMR 15 .305, and as - specifically noted on •PA'RT; C . FAILURE CRITERIA of this inspection :form. Inspector tignature' •Dat4 i'ded 'to the •pWN R, t•ht BUYER n e' copy of this eertl f i.o� Ut -,n must •berov. Omwhere gppl i•.c&ble) and th!i I39ARD OV. 1i8ALT11. .. * if the inspection FAIL•Eb., thv .cwner• .or operator shall . upg•v,Oo'the system. w � thin o'ne year of the da'" of theQinoveetion, unl®ss. a];'la'wsd Qr requ .;red on ?b 17 2016 22:21 Jim The Inspector Man 5085349919 page 1 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 1160 Phinney's Lane Building#2 W V Property Addressy OW` O? Arbor Terrace a Owner Owner's Name w information is CD required for every Hyannis MA 02601 2-11-16 p� .page. City/Town State Zip Code Date of Inspection CO 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 �/# ,��/� ���►►►UnuHlpi on the computer, (H OF use only the tab 1. Inspector. 4�`.. key to move your cursor-do not ' ' • G$ James D.Sears s JAMES use the return — Ri ac key. Name of Inspector =�: SEARS •—ram Capewide Enterprises,LLC Company Name 163 Commercial Street 5 INSPE�'��`���`` Company Address lnnntunq Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 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 2-13-16 spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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 Feb 17 2016 22:21 Jim The Inspector Man 5085349919 page 2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1160 Phinney's Lane Building#2 Property Address Arbor Terrace Owner Owner's Name Information is required for every Hyannis MA 02601 2-11-16 page. Cityrrown 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: The system is a 2000 Gal.Tank D Box and two pits. 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): 15ins•M3 Title 5 official Inspection Forth;Subsurface Sewage Disposal System•Page 2 of 17 r Feb 17 2016 22:21 Jim The Inspector Man 5085349919 page 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1.160 Phinney's Lane Building#2 Property Address Arbor Terrace Owner Owner's Name information is Hyannis MA 02601 2-11-16• required.for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumpstalarms 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 18.303(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 kispecdon Form Subsurface Sewage Disposal System-Page 3 of 17 Feb 17 2016 22:21 Jim The Inspector Man 5085349919 page 4 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1160 Phinney's Lane Building#2 Property Address Arbor Terrace Owner Owner's Name information required for every Hyannis MA 02601 2-11-16 page. City/Town State Zip Code Dale of Inspection B. Certification (cont.) 2. System will fall 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 sesspoek is less than 6" below invert or available volume is less than %day flow 15ins-3113- Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Feb 17 2016 22:21 Jim The Inspector Man 5086349919 page 5 Co mmonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 1160 Phinney's Lane Building#2 Property Address Arbor Terrace Owner Owner's Name Information is required for every Hyannis MA 02601 2-11-16 page. Cityrrown State Zip Cade 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. l5ins 31113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Feb 17 2016 22:22 Jim The Inspector Man 5085349919 page 6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 1160 Phinney's Lane Buildi ng#2 Property Address Arbor Terrace Owner Owner's.Name information is Hyannis required for every - y MA 02601 2-11-16 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): 8 Number of bedrooms (actual): 8 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 880 t5ins•i113 Title 5 Offialal Inspection Form:Subsurface Sewage Disposal S7s:em-Page 6 of 17 Feb 17 2016 2222 Jim The Inspector Man 5085349919 page 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1160 Phinney's Lane Building#2 Property Address Arbor Terrace Owner Owners Name information is required for every Hyannis MA 02601 2-11-16 page. City/Town State Zip Code Date of Inspection D. System Information Description: The system is a 2000 Gal Tank D Box and two pits. Number of current residents: unknown Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: PresentDate Commerciallindustrial 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 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Feb' 17 2016 22:22 Jim The Inspector Man 5085349919 page 8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1160 Phinney's Lane Building#2 Property Address Arbor Terrace Owner Owner's Name information is required for every -Hyannis annis MA 02601 2-11-16 page. citylrown 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: Yearly Pumping 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-3113 Title 5 Official Inspection Form:Subsurface,Sawage Disposal System-Page 8 of 17 r Feb 17 2016 22:22 Jim The Inspector Man 5085349919 page 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1160 Phinney's Lane Building#2 Property Address Arbor Terrace Owner Owner's Name requir required H annis MA 02601 2-11-16 required for every y 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: NA Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 40"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.): Pipeing is 4" pvc sch 40. Septic Tank(locate on site plan): Depth below grade: 30" feet Material of construction: ® concrete ❑ metal El 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: 2000 Gal. Precast H-20 1„ Sludge depth: t5ins•W3 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 9 of 17 Feb 17 2016 2222 Jim The Inspector Man 5085349919 page 10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1160 Phinney's Lane Building#2 Property Address Arbor Terrace Owner Owner's Name information is required for every Hyannis MA 02601 2-11-16 page. Cityrrown Stale Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 29e . Scum thickness 1" all Distance from top of scum to top of outlet tee or baffle v Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Asbuilt- Tape- Past Report Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank at 30" below grade w/both covers steel at grade.in and outlet tee. No sign of leakage or over loading. 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•3h3 Title 5 Official Irspection Form:Subsurface Sewage Diapoael System.-Page 10 of 17 Feb 17 2016 22:22 Jim The Inspector Man 5085345919 page 11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1160 Phinney's Lane Building #2 Property Address Arbor Terrace Owner Owner's Name informationis Hyannis MA 02601 2-11-16 requiredairedfor every 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): Dimensions`. Capacity: gallons Design Flow: gallons per day x 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•3113 Title 5 Official Ins lion Form:Subsurfaos Sewage Disposal pe g System•Page 11 of 17 Feb, 17 2016 22:23 Jim The Inspector Man 5085349919 page 12 Commonwealth of Massachusetts 191 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1160 Phinney's Lane Building#2 Property Address Arbor Terrace Owner Owner's Name information is Hyannis MA 02601 2-11-16. .required for every page. Cityfrown 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 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 44" below grade w/cover at 6". Box is clean and solid w/two lines out. No sign of over loading or solid carry over. 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: t5ina W12 Title 5 Official Inspection Form,Subsurface Sewage Disposal System•Page 12 of 17 Feb 17 2016 22:23 Jim The Inspector Man 5085349919 page 13 Commonwealth of Massachusetts Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1160 Phinney's Lane Building #2 Property Address Arbor Terrace Owner Owner's Name information is required for every Hyannis MA 02601 2-11-16 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number:. Z ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is two precast pits w/covers at 2"below grade. Pit#4" 3/4 full, Pit#3 2'water. No sign of over loading or high stain line or solid carry over. 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 l5ins-3/13 Title 5 Official Inspection Form:Subsurface Se wage Disposal System•Page 13 of 17 Feb 17 2016 2223 Jim The Inspector Man 5085349919 page 14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1160 Phinney's Lane Building#2 lug - Property Address Arbor Terrace Owner Owners Name information is required for every Hyannis MA 02601 2-11-16 page. CitylTown 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.): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 r Feb 17 2016 2223 Jim The Inspector Man 5085349919 page 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1160 Phinney's Lane Building#2 Property Address Arbor Terrace Owner Owners Name information is required for every -Hyannis annis MA 02601 2-11-16 page. Cityrrown 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 A f � o !3 �- - 1-7 C -3 K 3 C' .y ; 3,_ y 3 .� [Sins•313 Title 5 Offidel Ineoection Form:Subsurface Sewage Disposal Sysiem-Page 115 of 17 f Feb 17 2016 2223 Jim The Inspector Man 5085349919 page 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 1160 Phinney's Lane Building At 2 Property Address Arbor Terrace Owner Owner's Name information is required for every -Hyannis annis MA 02601 2-11-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth t high ground water: 2 feel 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: Per past report 20'+to G.K. Before filing this Inspection Report,please see Report Completeness Checklist on next page. 15ins-3/13 Title 5 Official Inspection Form:Subsurfaoe Sewage Disposal System-Page 16 of 17 Feb 17 2016 22:23 Jim The Inspector Man 5085349919 page 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1160 Phinney's Lane Building#2 Property Address Arbor Terrace Owner Owner's Name information is required for every Hyannis MA 02601 2-11-15 page. CitylTown 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-3/13 _ Title 5 Official Inspection Fortn:Subsurface Sewage Disposal System-Page 17 o1 17 '.. I r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1160 Phinney s Lane Building#2 Property Address Arbor"Terrace Condominiums Owner Owners Name information is required for every Centerville Ma 02632 12/19/2011 _ page. City(rown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any i way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information use o computer, bfl5 use only the tab 1. Inspector: - — kpXto move your cursor-do not Sean M. Jones use the return Name of Inspector key. Capewide Enterprises-;. r� <Compgly Name _ 153 Commercial St. Company Address M66kpee Ma. 02649 Cityltown State Zip Code 5087-8877 SI4522 Telephone Number License Number B. Certification Y' 1 certify that l 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: 2 Passes ❑ Conditionally Passes ❑ 'Fails ❑ Needs Further Evaluation by the Local Approving Authority r7 12/19/2011 Inspectors Signature Date The system inspector shall submit a co of this inspection report to the A rovin Authority Board Y P PY P P PPS, 9 Y( 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. w . ****This report only describes conditions at the time of inspection and under the conditionsi•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. V t5ins•11/10 Title 5 Official Inspection Forth:Subsurfa ;ewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1160 Phinne 's Lane Building#2 Y 9 Property Address Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma 02632 12/19/2011 every page. Cityrrown 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): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1160 Phinney's Lane Building#2 Property Address Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma 02632 12/19/2011 every page. Cityrrown 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•11/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 i Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1160 Phinney's Lane Building#2 Property Address Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma 02632 12/19/2011 every page. City/Town 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 El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow ` t5ins•11/10 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 �M 1160 Phinney's Lane Building#2 Property Address Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma 02632 12/19/2011 every 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. 0 ® The system fails. I have determined that one or more of the above failure o-+ 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-11110 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 1160 Phinney's Lane Building#2 Property Address Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma 02632 12/19/2011 every page. Cityrrown 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: Z ❑ 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 `IU02(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 8 Number of bedrooms(actual). 8 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 880 gpd t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1160 Phinney's Lane Building#2 Property Address Arbor Terrace Condominiums Owner Owners Name information is required for Centerville Ma 02632 12/19/2011 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: unknown 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 E No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commerciallindustrial 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-11/10 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 1160 Phinney's Lane Building#2 Property Address Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma 02632 12/19/2011 every page. Cityrrown 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: 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1160 Phinney's Lane Building#2 Property Address Arbor Terrace.Condominiums Owner Owner's Name information is required for Centerville Ma 02632 12/19/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 40"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line. 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints ok, no leakage, vented through roof Septic Tank(locate on site plan): Depth below grade: 30"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: 2000 gallons Sludge depth: 911 t5ins•11/10 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 1160.Phinney's Lane Building#2 Property Address Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma 02632 12/19/2011 every page. CityTTown 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 3.5' Scum thickness 4" Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 10.1 How were dimensions determined? opened covers and took measurements Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank needs to be cleaned now and again every year for proper maintenance. Outlet baffle intact, water level at bottom of outlet invert, tank not leaking and was structurally sound. Inlet and outlet covers are to grade. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1160 Phinney's Lane Building#2 Property Address Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma 02632 12/19/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity; liquid levels as related to outlet invert, evidence of leakage, etc.): 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•11110 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 M , ' 1160 Phinney's Lane Building#2 Property Address Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma 02632 12/19/2011 every 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 Oil Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box was functioning as intended. Cover is on a riser 6"below grade.. 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 v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1160 Phinney's Lane Building#2. Property Address Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma 02632 12/19/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number; dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Both pits were located and opened at inspection; pit#3 (on attached as-built) had 1' of available leaching. Pit#4 (on attached as-built) had 2'of available leaching. Both pit covers were on risers. 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-11/10 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 1160 Phinney's Lane Building#2 Property Address Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma 02632 12/19/2011 every page. Cityrrown 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.): l5ins•11/10 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 50 1160 Phinney's Lane Building#2 Property Address Arbor Terrace Condominiums Owner Owner's Name information is required for every Centerville Ma 02632 12/19/2011 page. Cityrrown 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 I 0 0 2 A_) 3/ C-3 q3 CO 30 3V t5ins•11110 Title 5 Official Inspection Fonn:'Subsurface Sewage Disposal System-.Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1160 Phinney's Lane. Building#2 Property Address Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma 02632' 12/19/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators; installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater elevation was established by accessing Town of Barnstable groundwater contour maps Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11/10 Title 5 Official 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 1160 Phinney's Lane Building#2 Property Address Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma 02632 12/19/2011 every page. Cityrrowh 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-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 J r _ Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 1160 Phinney's Lane (Building 2) Property Address Arbor Terrace Condominiums -2, 68 A Owner Owner's Name t information is Centerville Ma. 02632 required for 11/30/2007 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important:When filling out A. General Information • forms on the computer,use 1. Inspector: . only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC Company Name r� P.O.Box 763 Company Address Centerville Ma. 02632 ream City/Town State Zip Code (508)428-4028 S14454 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 Evaluation by the Local Approving Authority 11/30/2007 Inspector's Signatu a Date i The system inspector shall submit a copy of this inspection report to the Appro Ing AutWrlty(Board of Health or DEP)within 30 days of completing this inspection. If the system is p sharedsystem or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall sgmit the report to the appropriate regional office of the DEP. The original should be sQt to the-ystemw' wner and copies sent to the buyer, if applicable, and the approving authority. . =4 ****This report only describes conditions at the time of inspection and under the coaitio fir., s of use at that time. This inspection does not address how the system will perfo m in tWutur,6 under the same or different conditions of use. 1160 phinneys lane-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 r _ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 1160 Phinney's Lane (Building 2) Property Address P Y Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma. 02632 11/30/2007 every 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: ® 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: The septic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the-0 for the following statements. If"not determined,",please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed 1160 phinneys lane-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1160 Phinney's Lane (Building 2) Property Address Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma. 02632 11/30/2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times'a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced obstruction is.removed ND Explain: C) `Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ 'The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 1160 phinneys lane•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M ,. 1160 Phinney's Lane (Building 2) Property Address Arbor Terrace Condominiums Owner .Owner's Name information is required for Centerville Ma. 02632 11/30/2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory;for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or. less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No 0 ® 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 El due to an overloaded or clogged SAS or cesspool E ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow El ® 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. 1160 phinneys lane•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1160 Phinney's Lane (Building 2) Property Address Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma. 02632 11/30/2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. El ® 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 El ® 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 tributaryto 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. 1160 phinneys lane•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments e, wM 1160 Phinney's Lane (Building 2) Property Address Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma. 02632 11/30/2007 every 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)] 1160 phinneys lane•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1160 Phinney's Lane (Building 2) Property Address Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma. 02632 11/30/2007 - every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 8 Number of bedrooms (actual): 81 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 880 Number of current residents: NA Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No. Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage (gpd)): NA 9 ( Y 9 Sump pump? ❑' Yes ® No Last date of occupancy: 1a130/2007 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: Last date of occupancy/use: Date Other(describe): 1160 phinneys lane•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1160 Phinney's Lane (Building 2) Property Address Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma. 02632 11/30/2007 every page. City/Town State Zip Code Date of Inspection D. System'Information (cont.) General Information Pumping Records: , Source of information: Capewide.Enterprises,LLC Was system pumped as part of the inspection? ® Yes ❑ No If•yes, volume pumped: 2000 gallons How was quantity pumped determined? Measured Reason for pumping: Maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No 1160 phinneys lane-08/06' Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 E Commonwealth`of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1160 (Building 2Buildin Lane PhinneY's - ) Property Address Arbor Terrace Condominiums Owner Owners Name information is required for Centerville Ma. 02632. 11/30/2007, every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 18 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): 20'+ Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the building vents Septic Tank (locate on site plan): 30" Depth below grader feet Material of construction: ® concrete ❑`metal ❑fiberglass ❑ polyethylene ❑ other,(expiain) If tank is metal, list age: years - Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No --------------------------------------------------------------------------------------------------------------'------------ Dimensions: 2000 gallon Sludge depth: 0 Distance from top of sludge to bottom of outlet tee or baffle NA Scum thickness 0 Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA How were dimensions determined? Tank pumped at inspection 1160 phinneys lane-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 1160 Phinney's Lane (Building 2) Property Address Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma. 02632 11/30/2007 every 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.): Pump septic tank yearly.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears structurally sound. l 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 r Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or.baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection).(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): 1160 phinneys lane-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1160 Phinney's Lane (Building 2) Property Address Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma. 02632 11/30/2007 . every page. City/Town State. Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box is Ievel.Box has two outlet laterals with equal distribution.No evidence of solids carryover.No evidence of leakage. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 1160 phinneys lane•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5' Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 1160 Phinney's Lane (Building.2) Property Address Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma. 02632 " 11/30/2007 every page. City/Town State Zip Code. Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 2-1000 gallon ❑ 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.): ' Sandy soil.One leaching pit water to invert was 10'i at time of inspection.Other leaching pit water to invert was 54" at time of inspection.No signs of hydraulic failure. . 1160 phinneys lane-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary,Assessments M 1160 Phinney's Lane (Building 2) Property Address Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma. 02632 11/30/2007 every page. City/Town State Zip Code Date of Inspection , D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 1160 phinneys lane•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1160 Phinney's Lane (Building 2) Property Address Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma. . 02632 11/30/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. s Locate where public water supply enters the building. I - 0 1160 phinneys lane-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �^M 1160 Phinney's Lane (Building 2) Property Address Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma.- 02632 11/30/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ❑ "Check cellar ❑ Shallow wells Estimated depth to ground water:' Bottom of LP 12' feet Please indicate all methods used to determine the high groundwater 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: As-Built Card ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database - explain: You must describe how you,established the high ground water elevation: USED:Gaherty& Miller Model.12/16/94 groundwater elevations. USED:USGS observation well data June 1992. USED:Technical bulletin 92-000-01 plate#2 annual ranges of ground water elevations. 1160 phinneys lane•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 i • Town of Barnstable OF THE tp� Regulatory Services snxxsrnsi a Thomas F. Geiler, Director 9�AMA 6 9. r Public Health Division tEpMp`!A Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition,by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the"Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1160 Phnneys Lane, Building 3 M s Property Address Arbor Terrace Owner Owner's Name v information is required for every Hyannis MA 02601 2-11-16 page. Citylrown State Zip Code Date of Inspection t4 4 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 fillip out forms A. General Information on the computer, �� -jN OFrA4,q use only the tab 1. Inspector: �����' • key to move your a O? yG cursor-do not James D.Sears = JAMES use the return key. Name of Inspector � Capewide Enterprises,LLC 8 •. t1- �o r� Company Name 1.53 Commercial Street Company Address Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S 1623 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 Evaluation by the Local Approving Authority 0""�J�'L" 2-11-16 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system 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 4o #V-� 1 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 1160 Phnneys Lane, Building 3 Property Address Arbor Terrace Owner Owner's Name information is required for every Hyannis MA 02601 2-11-16 - page. CityrFown 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: The system is a 2000 Gal. Tank- 1000 Gal. Tank D Box and 50 chambers. 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-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 1160 Phnneys Lane, Building 3 Property Address Arbor Terrace Owner Owner's Name information is required for every Hyannis MA 02601 2-11-16 - 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1160 Phnneys Lane, Building 3 Property Address Arbor Terrace Owner Owner's Name information is required for every Hyannis MA 02601 2-11-16 page. City/Town 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 is less than 6" below invert or available volume is less than Y2 day flow A£,q @/,/I,v& Lt5,ns 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1160 Phnneys Lane, Building 3 Property Address Arbor Terrace Owner Owner's Name information is required for every Hyannis MA 02601 2-11-16 page. Cityrrown 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 1160 Phnneys Lane, Building 3 Property Address Arbor Terrace Owner Owner's Name information is required for every -Hyannis annis MA 02601 2-11-16 page. Cityrrown 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): 8 Number of bedrooms (actual): 8 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 880 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 i Commonwealth of Massachusetts w - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1160 Phnneys Lane, Building 3 Property Address Arbor Terrace Owner Owner's Name information is Hyannis MA 02601 2-11-16 required for every y page. City/Town State Zip Code Date of Inspection D. System Information Description: The system is a 2000 Gal. Tank- 1000 Gal. Tank D Box and 50 chambers. Number of current residents: NA Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: PresentDate 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 i Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 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 M y 1160 Phnneys Lane, Building 3 Property Address Arbor Terrace Owner Owner's Name information is required for every Hyannis MA 02601 2-11-16 page. Cityrrown 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: Yearly Pumping 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 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1160 Phnneys Lane, Building 3 Property Address Arbor Terrace Owner Owner's Name information is required for every -Hyannis annis MA 02601 2-11-16 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2009 Permit # 2009-386. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 46"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.): Pipeing at T -4' Pipeing 4" SCH 40 PVC Septic Tank(locate on site plan): Depth below grade: 40"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: 2000 Gal. H-20 1000 Gal H-10 Sludge depth: 1" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1160 Phnneys Lane, Building 3 Property Address Arbor Terrace Owner Owner's Name information is Hyannis MA 02601 2-11-16 required for every page. Cityrrown 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 NA Scum thickness 1 Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA How were dimensions determined? Asbuilt-Tape- Plan Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Two tanks-one 2000 Gal. H-20 with inlet Tee and steel cover at grade. Tank at 40" below grade. Tank at working level out let tee. Tank two, 1000 Gal H-10 at 42" below grade with cover at 9". In and out Tees, No sign of leakage or over loading. 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•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 , 1160 Phnneys Lane, Building 3 Property Address Arbor Terrace Owner Owner's Name information is required for every Hyannis MA 02601 2-11-16 page. Citylrown 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 i t5ins•3113 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 1160 Phnneys Lane, Building 3 Property Address Arbor Terrace Owner Owner's Name information is required for every -Hyannis annis MA 02601 2-11-16 page. CityrFown 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 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 54" below grade w/cover at 4". Box is clean and solid. No sign of over loading or solid carry over. Five lines out. 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: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1160 Phnneys Lane, Building 3 Property Address Arbor Terrace Owner Owner's Name information is required for every Hyannis MA 02601 2-11-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 50 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is 50 High Caps. Hand auger beside leaching and camra from D Box and back from vent pipe. No sign of over loading or solid carry over. 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 - o Not for Voluntary Assessments 9 p Y rY G1M ,a''e 1160 Phnneys Lane, Building 3 ' Property Address Arbor Terrace Owner Owner's Name information is required for every Hyannis MA 02601 2-11-16 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.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 1160 Phnneys Lane, Building 3 Property Address Arbor Terrace Owner Owner's Name information is required for every Hyannis MA 02601 2-11-16 page. City/Town 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 iS-s P4- , r°oo 3 a 0 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1160 Phnneys Lane, Building 3 Property Address Arbor Terrace Owner Owner's Name information is required for every Hyannis MA 02601 2-11-16 page. City/Town 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+' 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: Per past report BLDG 2. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official 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 1160 Phnneys Lane, Building 3 Property Address Arbor Terrace Owner Owner's Name information is required for every Hyannis MA 02601 2-11-16 page. Cityrrown 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments !� 1160 Phinneys Ln,_.BLDG 41' Property Address Arbor Terrace Owner Owner's Name information is required for every Hyannis MA 02601 5-7-12 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information ,,t►,,1+11ttl+►, filling out forms OF* on the computer, use only the tab 1. Inspector: �', JAMES key to move your cn cursor-do not James D Sears =of '=ARS use the return key. Name of Inspector Capewide Enterprises, LLC rab Company Name tp , _ 153 Commercial St.fA Company Address Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 . 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 Evaluation by the Local Approving Authority 5-7-12 pector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system 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 ofriciat Inspection WF.FmSubsurfac.Sewage Disposal System•Page 1'of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1160 Phinneys Ln, BLDG 4 Property Address Arbor Terrace Owner Owner's Name information is required for every y H annis MA 02601 5-7-12 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: ® 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): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1160 Phinneys Ln, BLDG 4 Property Address Arbor Terrace Owner Owner's Name information is required for every Hyannis MA 02601 5-7-12 page. Cityrrown 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 1160 Phinneys Ln, BLDG 4 Property Address Arbor Terrace Owner Owner's Name information is required for every Hyannis MA 02601 5-7-12 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/day flow t5ins•1 ill 0 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 1160 Phinneys Ln, BLDG 4 Property Address Arbor Terrace Owner Owner's Name information is required for every Hyannis MA 02601 5-7-12 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•11/10 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 1160 Phinneys Ln, BLDG 4 Property Address Arbor Terrace Owner Owner's Name information is required for every Hyannis MA 02601 5-7-12 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): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 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 1160 Phinneys Ln, BLDG 4 Property Address Arbor Terrace Owner Owner's Name information is required for every Hyannis MA 02601 5-7-12 page. City/Town State Zip Code Date of Inspection D. System Information Description:. Number of current residents: 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 (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1160 Phinneys Ln, BLDG 4 Property Address Arbor Terrace Owner Owner's Name information is required for every Hyannis MA 02601 5-7-12 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: 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts I� Title 5 Official Inspection Form m Subsurface Sewage Disposal System Form - Not for Voluntary Assessments -� 1160 Phinneys Ln, BLDG 4 Property Address Arbor Terrace Owner Owner's Name information is H annis MA 02601 5-7-12 required for every y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 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: 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: Sludge depth: t5ins•11/10 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 u 1160 Phinneys Ln, BLDG 4 Property Address Arbor Terrace Owner Owner's Name information is required for every Hyannis MA 02601 5-7-12 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 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? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form l Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1160 Phinneys Ln, BLDG 4 Property Address Arbor Terrace Owner Owner's Name information is required for every Hyannis MA 02601 5-7-12 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): 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 C Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1160 Phinneys Ln, BLDG 4 Property Address Arbor Terrace Owner Owner's Name information is required for every Hyannis MA 02601 5-7-12 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 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ 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 Title 5 Official Inspection Form e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments v � 1160 Phinneys Ln, BLDG 4 Property Address Arbor Terrace Owner Owner's Name information is H annis MA 02601 5-7-12 required for every y page. City/Town State Zip Code 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: ❑ 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.): 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•11/10 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 1160 Phinneys Ln, BLDG 4 Property Address Arbor Terrace Owner Owner's Name information is required for every Hyannis MA 02601 5-7-12 page. Cityrrown 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.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts ;Title 5 Official Inspection Form I o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1160 Phinneys Ln, BLDG 4 Property Address Arbor Terrace Owner Owner's Name information is required for every Hyannis MA 02601 5-7-12 page. Cityrrown 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 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Counna-mosm Of I fue . Officiatinspection Fonn 1160 M LT-4- SWG 4 AdXo- Tempe LL ifs - -- - _ Pap- stm Z�p code Smmh€ f smage,Dispowsystarn provde a Yam, € _LOW*ON waft Wdhin took - _.me r ,, in UPSC drmqfing M . � F mt Val of } 7 t. f a r9a a€ rS�i�a S�sr t-SyStwn,P3Me 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form f' a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1160 Phinneys Ln, BLDG 4 Property Address Arbor Terrace Owner Owner's Name information is required for every Hyannis MA 02601 5-7-12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 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: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 V . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1160 Phinneys Ln, BLDG 4 Property Address Arbor Terrace Owner Owner's Name information is required for every Hyannis MA 02601 5-7-12 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 1160 Phinney s Lane (Bldg.4) Property Address Arbor Terrace Condominiums ' Owner Owner's Name information is required for Centerville Ma. 02632 10/20/2009 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: - A. General Information When filling out forms on the computer,use 1. Inspector: oniy-the tab key . to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name P.O.Box 763 Company Address. Centerville Ma. 02632 City/Town State Zip Code (508)428-4028 S14454 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 1�1;40 ofi, Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority s . cxy cr. 10/20/2009 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1160 Phinney's Lane (BIdg.4) Property Address Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma. 02632 10/20/2009 every 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: ® 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: The septic system is in proper working order at the present time. 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•09/08 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 �nM 1160 Phinney's Lane (Bldg.4) Property Address Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma. 02632 10/20/2009 every page. City/Town 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal.System Form - Not for Voluntary Assessments 1160 Phinney's Lane(Bldg.4) Property Address Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma. 02632 10/20/2009 every page. City/Town 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 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 Y2 day flow t5ins•09/08 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 1160 Phinney's Lane (Bldg.4) Property Address Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma. 02632 10/20/2009 ' every 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 1160 Phinney's Lane (Bldg.4) Property Address Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma. 02632 10/20/2009 every 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): 8 Number of bedrooms (actual): 8 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 880 t5ins•09/08 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 ;M 1160 Phinney's Lane (Bldg.4) Property Address Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma. 02632 10/20/2009 every page. City/Town State Zip Code Date of Inspection D. System Information Description: The septic system consists of a 2000 gallon tank,D-Box and two leaching pits. Number of current residents: Unknown Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage NA 9 ( Y 9 (gPd))� Detail: Sump Pum ? ❑ Yes No P Last date of occupancy: 10/20/2009 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 M Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 I� II Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1160 Phinney's Lane (Bldg.4) Property Address Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma. 02632 10/20/2009 every 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: 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•09/08 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 °M 1160 Phinney's Lane (Bldg.4) Property Address Arbor Terrace Condominiums Owner Owner's Name information is Centerville Ma. 02632 10/20/2009 required for every 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: 1983 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 3' Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+ feet Comments (on condition of joints,venting, evidence of leakage, etc.): Joints appear tight.No.evidence of Ieakage.System vented through the building vents. Septic Tank(locate on site plan): Depth below grade: 2'5' p g 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: 2000 gallon Sludge depth: 3" t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts H Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments e wM 1160 Phinney's Lane (Bldg.4) Property Address Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma. 02632 10/20/2009 every 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 34" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 13" 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.): Pump tank yearly.inlet and outlet tees are in place.No evidence of leakage.Tank appears structurally sound. 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-09/08 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 �M 1160 Phinney's Lane (Bldg.4) Property Address Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma. 02632 10/20/2009 every 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): 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•09/08 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 ;M 1160 Phinney's Lane (Bldg.4) Property Address Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma. 02632 10/20/2009 every 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 No Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box is level.Box has two outlet Iaterals.No evidence of solids carryover.No evidence of leakage. 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•09/08 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 f - Commonwealth of Massachusetts Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 1160 Phinney's Lane (Bldg.4) Property Address Arbor Terrace Condominiums Owner Owner's Name information is Centerville Ma. 02632 10/20/2009 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy soil.No signs of hydraulic failure.Pit#1 was dry.Stainline up to invert.Pit#2 water to invert.5'.No stain line higher. 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-09/08 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 �M 1160 Phinney's Lane(Bldg.4) Property Address Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma. 02632 10/20/2009 every 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.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 iL Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1160 Phinney's Lane (Bldg.4) Property Address Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma. 02632 10/20/2009 every page. Cityrrown 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 Of .• ,•• ob ti �3r tit t5ins•09/08 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 ° M 1160 Phinney's Lane (Bldg.4) Property Address Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma. 02632 10/20/2009 every page. City/Town 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: Bottom of LP 40' 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: USED:USGS Observation Well Data.USED:Technical Bulle yin 92-0001 plate#2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 i K� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1160 Phinney's Lane (Bldg.4) Property Address - Arbor Terrace Condominiums Owner Owner's Name information is required for Centerville Ma. 02632 10/20/2009, every page. Cityrrown 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 i COMMONWEALTH OF MASSACBUSETTS EXECUTIVE OFFICE'OF M4MON M4TAL AFFAIRS DEPARTMENT or ENVIRONMENTAL PROTECTION TrILE S OFFICIAL INSPEC nON FORM NW-FOA VOLUNTARY ASSESSNIEW $ SUMURFACE SEWAG$DISPOSAL,SYSTEM FORM 1 PART•A CERTIFICATION Property Address: .. 116 0 ah in h e yA f,7ne 11 a.i t • a�an.ze O"OeIName: Apt opt 7e47aea CoadaA Owner's Address: a a,a o, Date of Iaspectioa: t'>i o L10 5 Nub of Iospeetor.(plem,pMn t A Sao Cosspany Nam .R ac. Mailing Addtew en &4v4 a aaa.•02632 Tdophose Number- - CERTIFICATION STATEMENT I oadfy that 1 have personally inspected thasawege disposal system at this address and that the information reported is to below *a emote and complete.as o'f the time of the hgwtloL The ftspeaion was peribrmed based co my training sod experience in the p"er fmxd m and maintaasace of on-site sewage disposal systems.I am a DEP app*oveil sum inspector pursuant to Seedoa.1&3d0 of.Tide S(310 CMR ILOW) The system: -condwouny Passes Needs Further Emgmion by the Local Approving Authority Iattpe¢tor'a S�natAre: Data,fig_ The system inspector shall submit a copy of this inspection repast to do-Appmvind Authority(Bard of Health or DEP)within 30 days of oompleting this hnpecdoL Ihhe iysten!is a Owed system or has a design flow of 10,000 gpd or giealer,tee hopecror and the system owow.aluit Wxdt the report to the appeopri t ngioosl office of the DEP.The original should be sent Lathe system owner ad copies sun to the buye4 if gplkable,and the%Vmvios anthodty. Notes and Comments •***nb rgwit only describes condition at the flare of laspedlea sad under the conditions of use at that time.This Inspection does not address how the system will perform in the fixture tinder the state or Merest conditions of use. Title 5 htgmcdon Form 611 S12000 page 1 OMaAL INSP$CTION:FORM--Nar FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSUM INSPE4' ON•F0RM' PAKr A CERTIFICATION(continued) property Adm 1160 PA-buzelya Lane_ Blast 4 Ow"r; RagoA If.44ack COAR0.6 Dats of Inspedion: baPecdoe-Sasimt W- Cheek A JI C,D or E/, aaapibeh,a®of Section A. symn Pam: yes NO I havoc not&=d any informa im whisk indiCa **=y of the Mum criteria described in M cm 13.303 or in 3lo C11Rt 15.304 exist.Any adore criteaia not evaluated are indicted below. Cosomentr. _f Semis auetaeae -ia .iA naoPe4 m6Akina o4de4 at he Mehent time It. System CoaditloLslly Passes: 80 One of mote.rfl m componemts-as described in dn"Cesdillooal Pass"section mW to'be repbced or ;,>• repaieed.'Ibe system npoa completion of the replaced or replk a approved by d*Board of 1108104 will pass. Answer yea,no or not.daetmined(Y,NND)in the for the fbllowing atatemettta.If"not daermined"please explain. A o The a tank is metal and.vw X yearn old'or the septic tank(w� hether-mCtal or not)ia.stra�y uosovz*"Ibits substantial infPt W=or afiltradon or tank failure is-imminent,System will pas inspwdon if the existing tank is rephcad with a complying septic taplSn fffwved by dw Board of.Heakh. +A metal septic tank will pass i gmtlon if it is WochnUy sound.not baking and if a Certificate of Compliance indicating the the tank is Ion thaw 20 years old is available. ? ND explain: } no Observation of i sewage backup err break out or high static water level In the distribution boot due to broken or obsttuuccted pipes)at due to a bmka%settled or mom m dist'bution boat.System wM peas w*ocdonJf(witb a oval of Boad of Rialto): . .. broken popes)an nep]goed . i obstretC4oa is raa0ve4 . dtatriiSettion boat is vekd or t''eploced ND explaiar t + no The system required pumping moue than a times a due tobMkm or obstructed . as if with Y� pipe(s�The system will i pas,bgeW ( approval of the Boatel of Ii with): ' broken pipes)an repbocd } obstnwdon is removed 1 ND explain: -`+ 2-. / I t OFMCIAL'INSPECTION FORM-NOT IVOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISP0&O1L SYSTEM I1NSP .MON FOR_ M PART-A 'CERIMCATION(continued) 'PropertyAddM: 1160 Ph.ItLne e••Lane Iln•it 4 anti Owner: A4804 e41Laee Condo-6 Date e f Inspection: 1219102 C. Further Evaluation-is Required by the Board of Health: 40 Cmatdidom exist which.roqui m further evaluation by the Baat+d.of Healtb iu order to determine if the system �8�Proms i��h�lth,safetl+or the enviromneat. . 1. System will pass unless Board,of Health determines U accordance with 310 CMR 15.3M)(b)that the ? system it trot functioning In a&saw which-will protect public health,safety and the enviroament: n o is within 50 feet of a surface water �?°Cesspoolm of privy is within 50 fed of a botdutg vegetated wetland or a salt marsh r - t , 2. System will fag unless the Board of Health(and Puplk Water Supplier,If any)determines that the system Is functioning in a manner that protects the public ha W safety and environment: no The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 fw of a surface water supply or m'butary to a surface water supply. ?C The-system-has a septic tank and SAS ern the SAS is within a Tone 1 of 8.public water-supply. ?o The system has a septic tank and.SAS'and the SAS is within 50!ice of a private water supply weS. _p the system has a septic tank aqd SAS and the SAS is less than 100 fW but 50 foes or mom foss a private water supply well•.Method used to determine distance P,1 b u a P. 00, ••This system passer if tho well water analysis6 per&rmW at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is On from pollution£roust that facility and E the presence of ammonia nitrogen and nitrate nitrogen is equal to or leas than 5.ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. Other: l _ i . • a • 1 • 3 F r OFFICIAL.INSPEMON FORM-NOT-FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM DMECTION FORM PART A . ; CERTIFICATION(oominuto Pt'+opertyAddres: 1160 Ahlnneya Lane Iln-it 4 _ y7,yann74 Owasr-At I 0' lee . oa o e i Date of lmpeetion: D. S�ftm Faihtte Cyltub applieame to all systems: You fila lndicase"Ym'�or"no"to each of fly fonowing,for Jawpoctiom Yes No _ . X Badm:p of sewage into facility or system comp00ent due:tea overloaded at clogged SAS or cesspool f Discharge or ponding of effluent to the surface of the ground or sutfftce waters due to an overloaded or clogged SAS or cesspool X SMM h"d level in the distribution box above outlet invert due to an overloaded or clo' cesspoolSAS ter X } — Liquid depth in=upool is leaf than 6"below invert or avaftle vohuae is bus than%ft flow Required— oPthaes Qtmtping mane than 4 times in the lest year=drm to clogged or pumped obatrtrcted pipe(S).Number Any portion theof S S,cesspool cc Privy is below high ground water elevation. Any portion of cesspool or Privy is within 100 feet of a smfwe water Supply or tri)utary►to a surface ' x supply. I A"p cesspool or privy is within a 3Me-1 Of Public well. ._ Any.portio n of a cesspool or Privy is within SO feet;fa private water supply well. _ Any portion of a cesspool or privy is boa than 100 feet bun great than 50 EM frost it private water t snpPly well with no acceptable water quality analysis.rrhb system paw U the well water analysis, Performed at a DEP certified bboratory,for eoilform bacteria and vt'lat0e organk oompoonds. iadleatas that the well b fires fl"om pollution from.that hcWty and the presence of ammenls nitrogen and nitrate nitrogen is equal to or less than S ppm.provided that no other failure Criteria are triggered.A copy of the anatmis must be attaehed.to thb f".] NO (Yes/No)The m � 1&I bave determined that one ormore*f the above failui*criteria exist as descn'bcd in 310 CMR 15.303,dmmfmc the system falls.The system own er„�uld contact the Board of Health to determine what will be necessary to corned the faihn . E. Large Systems: To be considered a large system the r system mast serve a•lacility with a design flaw of 10,000 gpd to 15,000 �mvst indicate either"yes"or`W to,each of the following: (The following criteria apply to 14W systems in addition to the ork eda-above) � 1 _ the system is within 400 feet oft Surface drinking water.Supply — -.,L the system is within 200 feet of a tributary to a surbee drinking water supply r the system is located 1n a niftSen sensitive an(Trmterlm Wellhead Protection Area—IWPA)or a»te�pped i Zone 11 ofa public water supply well If you have saswered "to un syarom is considered a sigrriflcmt threat,or answered i "yea"at Section D above the btge has Wed.�owner or operator of an significaet threat under Section E or failed under Section D shell e �ism ce with 31 a , i 15.304.The system owner should contact the time System in accordance whit 310 CIrQt aPProP�regional otlioe of the Department. i 4 1 t 1 OMCIAL INSPECTION FORM—NOT-FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEG.'FION>H`ORM PART B CHECKLIST Property Address:_1160 Ph�Rn - jan a �1►r i t 4 Owner.ARgo4 U44aee Date of Inspecdon; Check if the folio have been done.You asost indicate OW or"w"as to ewh.of tlis folk ' Yes No _ moping information was provided by the owner,occupant.or Board of Health were say of the system its pumped out in the previous two weeks? X _ Has the system received nornW flows in the previous two week period? X Have hW volumes of watt been introduced to the system recently or as part ofthis'7nBpOCtlon.? . Ware as baih plans of the system obtained and examined?(If they wen not avallable note n NIA) X _ Was the facility or dwelling hupcetod for signs of� aQwgga back up Y- Was the site inspected for signs of break out? �. — Were ail system cornponerda,excluding the SAS,located on site? x were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition V of the baffles or top,material of cwisiructioa,dimensiw;s,depth of liquid,depth of sludge and depth of scum T Maintenancees the facliftsubsurface sewage and occupants if different from owner')provided with information on the proper of disposal systems? The sire and loeativa of the$oil Absorption System(SAS)on the site has been determined based on: Yes no Existing information.For example.a plm at�he Board of Health. j 1 _ Determined in the field(if any of the failure criteria rebded to Part C is at issue appsoximetioa of distance is anaooepRabie)[310 CMIt 15.3M(3)(b)J 1 t f OFFICIAL IIVSPF,C1'TON FQRM—NOS'FOR VOLUNTARY ASSESSMENTS SUBSMACE SEWAGE DISiPOSALSYMM_ NSPEMON FORM PART C SYSTEM INitOR1�+IAT,ION Prope*Addrew 1160 Ahinneae Lane Unit 4 OWUr..AR1OR e�!( Raba Data of Inspeedoa: 7,279105— - FLOW CONDITIONS RESMENTIAL . Number of bad ==(deaign): - 8 himnbsr of t edwoms Coon!):8_ DESIGN flow based an 310 CA+IR 15.203(for eiaimp1e:110 gpd x#of bedroomy' 880 Ntmzbw of current residents• u nkn o w Does residence have a 68e t or no no (yea r. h laundry on a separate sewage system(yes of no):?oo [if yes separate inspection required] + La»adry system inspected(yes or no)-,W Seeaonal use:(yes or no):r"_ Wester meter readings,if evallWe(lost 2 yoara usage(gpd)): sump pump(yes of no):An Last date ofooctipncy: RAAA at C011DV UCUL,ll1�'DURNAL Type of estab' N/A Design flow as 310 CM R 15.203): _ �pd Henn of desi�r'$ow{sersomisgieetc.): a Grease trap present(yea or nor_ Industrial waste holding tank present(yea or no): Non-sanitary waste discharged to the Tide S syatan'(yea or no): Watc.meter readings,if available: Last date of occupencyhtse: OTHER(describe) . Pumping Recoriis GENERAL WFORMATION ' Source of information: yeas ley •i + Was system pumped as part of the inspection(yes or no):_ IRelaaon oh pep d._ gallons—How was quantity pumped determined? r T OF SYSTEM _Sep ie tank,distribtrtlon box,soil absoq*=system Single cesspool _Overflow cesspool _Shared systent(yes or no)(if yes,attach previous inspection raxuds,if any) Innovadve/Alternadve technology.Attach a copy of the current operation and maintenam contract(to be t obtained from system owner) _Tight ink ,___Ansch a copy of rho DEP approval Omer(describe): Appt ooci Date age of all components,date installed(if lmown and source of information: i 20 yea4J ) FWass acwago odors dcncted when arriving at the site(yes or no):B 2 ti • t . i OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Propetty Address:1160. Ph.dnne .6 Lane -[nit 4 Uan 46 Owner:Athos Teaaaed COndOb ' f Date of fasp etioa: f BI;IILDING Sj%U(babe on site plan) Depth below grade: 18' Materials of conswction: cant irmt _L40 PVC!other(evwm): Distance froth private water supply well or sactioa line: ?? o n b jnd 1 in, ,evidence of i ( n tngt. Vented thaou h �ictLding j SEPTIC TANKf/ed(looate an site plan) 2000 'ga tt o red Depthbdowgrs&: et 94ada Material of co�truetlon: X oonaeao;M"_fiberglass__olyethylene other(atplaia) --� Ifs metal list age:_ 'L age can8naed by a CatiRate df Compliance(yea or ao):_(gmwh a copy of Dimensions: 12 X 5'8'X 6'6 v Sludge depth: . tRace Distance from top of shuip to bottom of out!�or baffle: t�z„ ace. Scum dtidmess: t?a c e Distance from top of scum to top of outlet tee or battle: Le a c e Distance from bottoms of scum to bottom of outlet tee or Wr a`R eS e How were dimensions determined: ,e eau.6R ed . Comments(an pumping datf ors,inlet and outlet tee or baffle condition,structuml integrity,liquid levels' as related to outlet invert,evidence of leWugA etc.): Pump tank _yaaRtey: I_ ntet 8 outlet �on.� i 674uctu4azz Bound. � .�—�a�k ;,A GREASE TRAP:no_(locate an site plea) Depth below grade: Material of eoasauaion: concrete metal fibergbm_polyethylene other h(rxplain}; Dimensions: Senn thickAess: Distance from top of Scum i tap of outlet tee or baffle: Distance floor.bottom of scum to bottom of outlet tee or baffle: ! Date of last pumping: Commatb(On pUnpi m mmendations,inlet and outlet to or baffle.condition,structural Integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): I y4ea6e t4pa L4 nO.t /1/Led2R t � I t 7 r mom OFFICIAL I(N.SPECTION PORN—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r-- PART C SYSTEM EMRMATION(oonw►um4 PrepertyAddrean 1160 PAinneue Lane Iln.it 4 Owner: A41 o at- 7en� Date etItmpeegon• . ASQGP- TIGHT or HOLDING TANKS n o (auk mast be p=wW at time of iagmW1onxlocaoe on site pLn) Depth below Waft Material ofc. truction: pmw to mete! fiberglass,.,_ polyethylene odw(eglain): Dimensions: E ®lions ' Deign Flow: Olondday Alarm present(yes or no): Ahem level: Alarm in wwaddag order(yea.orno):- Date of last pmopf. t Commob(aomdit=dalarm and moat mcbes,etc.} Ught on holding tankb aze not ARe.eeal DL4 MUTTON BOX: ye 4(if present moat be opened)(locaae an site plan) j Depdt of liquid level above onikt inveat: 0 Cantmenn(note if box is JeW and distribudon to oaten equal,any evidem of solids Wryover,any evidence of leakage into or out of boot,etc.): .in oa out old fox., i PUMP CHAMBER: 110(locste on site plan) 04V Pumps in worlriag order(yea or no): Alm=in working order(yea or no): C (pole rn e titis�t d of p nb ,co±+. Siva o(pampa ad appm-sn—mm etc.): Pump cha ,c tb no peasant i } 8 IS - L� _ Abu OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEMOX FORM PART C SYSTEM INFORMATION(condm,4 Property Address: 1160 PU124eyz Lane Unit 4 Kaanniz 0nw ; ARgoR feRRace Date of lawedoe: 1219705 } SOII.ABSORPTION SYST$M(SASx i({oab a ills pbn,euavation sot required) 1 USAS not located explain why: Located zee X- leaclna pits,number: 2 Inching clhambas,umber. Inching PECriea,-number. Inching trenches,member,length: leaching ftalds,number,dimensions: overflow cesspool,number: innovativeJslternative system Type/nome oftwb Wogy:, y Comments(note condition of soil.slam of hydraulic failure,level of ponding,damp soil,condition of vegetation, Loamy to met{use zandr No zi nz o y �C �aitu o c,.:B. RU P49 n i..i Z6 noutaL oR a nn, nne CESSPOOLS: no (cesspool must be pumped as part of inspectionxiocate on site plan) . Number and configumdon: Depth—top of liquid to inlet invert: Depth of solids layer: . Depth of scum layer. Dimensions of cesspool:- Materials of constriction: Indication of gr adwatrr inflow(yes+or no): Comments(note condition of soil,signs of hydraulic fature,level of pondi.wa condition of vegeM.-lion,ft.): cezzP001a aRe not PAehent PRIVY:no(locate on site plan) Materials of construction: Dimensions: Depth of solids: Cotmnents(note condition of soli,signs of hydraulic failure,Ievei of ponding,condition of vegetation,etc.}: pRiuu iz Refs �ReapRt . 9 i OF TAL INSPECTION FORM.-NOT FOR VOLUNTARY ASSESSMEM ACE SEWAfX:DISPQSAL SWUM STEM INSPECTION FORM \ PART C SYSTEM INFORMATION(tia Wnued) PrWrtYAddraa: 1160 Ph Laneus fano. 1/.n i f 4 Owner: 44804 eR� ca oa Date of Iespectlo8: 105 . Si WCH OF SEWAGE DL94XAL SYSTEM P o"a sketch ofthe sewage disposal ays,=iwtuft ties to at lam two beachia,Loans an wells within 100 feet Locate when � Perot P wmer supply enters the b=m l or i 1 �97 +� sit 10 .rat a efu ""-'-` " CI1�liC'�AZ P"�G7ZON•l�ORM�NOTS+OR�f►OT.UNTA,RY A8S�38ME>YTS . SOMMAM SEWAGE STU M II�iSPECrION.�ORM i PART C y SYft M-DftRMAnON(oottotintted) �alnneu_b Lu,ce U&if .4 � y Oweer; W04 44a'ce Sondoe Datae[Iaapeetlon• an MUM way Cho*ccgw Shan&W wells Aged depth to ground water 7 0. fm - Pleae iadicaeo(t he k)all methods need to da twin the Milt Vaud water elevation: NO Obtaiood 8om timnk deeigs p6ma of raeea�d-Itaherbd.dose dedOn pLa reviewed= W+ ( f hole wlehia ISO hat of y Cbedoed wkh hxal-Board ofH o Chedoed with local eotoavattim ioat 1wil-(attieh d enaoamtiteiom) g"&cm 4UMdatabaweotpldnAtfp:towa;otaanbtaile.,ma..ue r You most describe haw YOU abed the bkb ground watt•elwmm: llded. : Cape Cod Coeemlaion Mateo 7atte CoA ou&A And 'Puttic Mate-t Suppty l 6►ell----7ead goo ec io-n a ceae map.- $lat 99-5 �latew ,e _aeu� _g` e�f��e sans cod caaratieion � Leeching Pit 10,;set Ommdwatcr6 Fcot Below Botwm: -6f Pit High ClroundwaEer Adjuatmeat i:6 ft Frith. .. + Pa ptgr Method nemfore,the vertical• 4 B. . Of tbs I n and arparadon diaWm itetwe�the bMih °�ti P &dJustcd&Youodwatar table is 5 5.,,2 fwL ;a i 7 r "Wit 011 BdNN.ti.Vdgglr DW=*QP UNA1,711 1WIt18URFAC9 S1WAOR DISPOSAL BY8't'R11.I1181'=10N FARM • PART D C<; ITICATION w•�.w t -Tyra on !RUNT otsmT- { ,PRQPirwr tvUSPBG'rRD 1140 Phinneye Lane Un:li 4 '. STREET ADDRBSQ �....� ASSESSORS MAP, BLOOK AND 'PARCEL d ' ' � AAAoR 7eaAaca •Conodod ' ONNBR!s RAMS PART••,D — 08Rl7Fr AT4oN ; RAMS 1017 INSPECTORCOMPA - R,,,e x.L � � • • . . NY MAHE loeeAh =P.+ Rac9s6a: 'Son Ina ' COMPANY MUSS ,' Box 66 -C&A""ev.tlle Aa�s' 02NS32 s �• oVNN•os GIW ZIP COMPANY T969PHONS ( 508. 1:t73 - 333g •gam 508-.V90 f 578 CBRT•I'FICATION, STATSHBNT I certify that I have persotiatly :inspected tltb Newage 'didjosil. system at his address and that thif Intormation reported .is truep gootiratea gfid omplete aq of the time jqf•inspeation.r The invV6014n US perforaed and Any ecommendations regard.ing upgrade-1 .maintenances- abd rePair,ai'e• 00U418tent With nay traLpioX and experience in th4 .ppoper futrotinr' artd inaintetkance of on- its sewage disposal system$. Check ones :a , , xXoysted PASAD 1 The inspectioh whio.h •1 }Navq conduoted has ..npt found any lufdrmation . which indicates than the syitsm' Sails to'ade4ijetely. protect .publio health or the enviropment as defined it>• .410 CHIT. 1t:30.3•9 -Arty failure = criteria Aso t evaluated are as stated in the FAILURQ' CRI-TWA station Of this, form. 87stem FAILRD# • The inspection which I have p4h ted-has'sound that the eystem fails to protect the public Health pnd the enxi,ronment ' in agoordance with 'title 6l 310 CHR 16.303, and as•speciticaily noted -on •PAIR.?'C o.. 1FAILVRe CRITERIA o; this inspec ion .f ' w ' Inspector Signature* D it4. e-A10-5 ne copy of th-ic csptl f icgt•iatt must -be vrovtdid 'to ,the pWNRR•a it* purza where appliaabla) and thlotl t3QARD OF NZALT11a * X t the inepeotlen FAIL19j). tttlti ,owne'r'.ot•'"9Perator a!?aal3,.vp8NN'�adi'Wts system. within one year of the date of the inspection, unless: aijiLawad oN. xepitired .,r.hav-wise as provided in 44A0 CHR 16.0061 ' ww%4A •.tww. Jt J j TOWN or B�sw•8,t6_......... noA� or n$AITH t { BUOMPAOR RENAOR D1sPMt, SVBTXM Is PEMION MN - PART D•- CBMTIFICAT'ION } •t, .-.n•r•rtin,w...r.aianr�w •, .rite 0� P1tl�T CI�A�bY- `' PROPirm IN,8P=jrQ f r 1 f 60 Phinhey,a Lane Unit ' 8TR81S'i' ADORES S �^,�.�...., ...,.�.., ..�..�.._.w_..,r.-:�.... f ,r.6y `y a A88888OR8 MAP j BLOOK AND 'PARCEL i ktloa teRRace -Condo.b o OWNER s NAME • PA7tT•--D - =Irr�'rc�+rJrox ; f RAMS OF INSPECTOR _ R0Bisl P.aoel COMPANY NAMB 1obeA1► :P�l7acoxt•e `$na Inc ; ' ,r• Box 66 .Ctntaau.LLti Rabb' 02632 ' COMPANY ADDWS Town-or GIVY. - }{1. ••f.' COMPANY TSLSPHONB t 908• ft73 - 3338 •PAX 1'S08;1i'90 f371 VI CERT-1-FICATION. STATEMENT • " I certify that I haivo persoeiai'lY .lnepsoted ttfe mewage 'dispoedY. system let his address and that Mile inf-ormation peported ,la true,. 400dratey acid S omplete aF of the time .,qf finspmction,. The inspectfon mast perftraaed and any `•' ecommendations regard-ing upgrade., .Wntenanoe,• and repair .ale•. ovneistsnt ' with my trainigg and experience in the-:proper futrotion• and maintenance of on- site sewage disposal systems. Cheek ones :d ; ' XXXSystea! PA$S$D . r y ' Q The inspection which I have conduoted has .,n*t foyind any infdrmation . which indiostes that- the systow Sails to',ade4ustely, protect -public ? =� health or the environment as defined in .410 CHR. 1C303•1 -Any faiiitre criteria trot evaluated are as stated in the FAILURS CRITA .seetion a-f this. form. ' '��y System .FAIL•SDe - - • The inspection whicl, I have n tea has Sound Chat the gystem laiis to co protect the public health pnd the environment' in a¢eordshoe with 'title 60 310 CHR 16.303 s and as-specifically-noted -op •PA1tr•O -. FriILURz CRITERIA off' this . ins ection .ior aw inspector Signature• ��' Dat4. 4 n4 oopy Qf th-is certl f1-cot.ictn must •be �r�.ovidsd :to the' '.OWHIR•, b* BUYRR where appli•oable) and ship 29ARD Or H3AL'CA. .. ` • If the inspection BAILitb, thti .ewAeb'.oe9pe6tor -a%Wll•uppv*de'•the system. within ene year of the dais of the inspections unless, AX10wad Qrr reghJred as .provided in V4 CMR la S06 , n f.f+wrw I> COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS I ( . _ DEPARTMENT OF ENVIRONMENTAL PR ��ECTI7 , ? O ONE HINTER STREET. BOSTON, MA 02108 617-129 S°00 N ILLI.�N1 F %k ELDTIRL DI COXI Go�cmor use T�/ti OF �9 Sc:rc i S y�A(Ty 9NSr 8 IA•.i ARGEO PALL CELLLCCI _t ,� OFprAg�F D.��w.D B STRL it' Go�cmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION rLFORM PART A �� �y CERTIFICATION Unit 1 A Arbor Terrace - Property Address: Condo' s Phinneys Lane Hy. Address of Owner: Date of I nspection:4/1 7/9 8 # 1 1 6 9 (If different) Name of Inspector) er Jr. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: J.P.Macomber & Son Inc. Mailing Address: BOX 66 Centerville,Mass . 02632 Telephone Number: 508-775-3138 CERTIFICATION STATEMENT I certihi that I have personally inspected the sewage disposal system at this address and that the information reported below is true. accura*e and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function ano maintenance of on-site sewage disposal systems. The system: d Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing In's 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 sysiem owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A) SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 1 3 303 Any failure criteria not evaluated are indicated below. COMMENTS: B) SYSTEM CONDITIONALLY PASSES: ,LlrJ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The S,Stem, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not .G)U The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tan, as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 DEP on the Wortd Wide Web. hnp./Nwww magnet state ma us/dep Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORS• PART A CERTIFICATION (continued) P,0:er11 Act(ess: Unit 1 A Arbor Terrace Condo' s fii Meys Lane Hyannis,Mass . ��^er David Hirsch :),:c Of i spc(: On �/17/98 ! SYSTE.,-A CONDITIONALLY PASSES (continued) Sewage backup or breakout or high sta(tc water level observed In the dislrlbt,llon box ptpe(s) or due to a broken, sealed or uneven distribution box. The system will pass ns;oec,.,:f Board of Health). Describe observations: broken pipes) are replaced obstruction is removed distribution box is levelled or replaced S The system requ,red pump,ng more than (our times a year due to broken or obstr C!ec ,specs.on if (with approval of the Board of Health) broken p,pelsl are replaced obstrucl,on is remOvec C FURTnER EVALUATION IS REQUIRED BY THE 80ARD OF HEALTH: Core tons ex,st which require funher evaluation by the Board of Health in order to dele,r-`,n? o c health, wfery and the environment 1i SYSTEM WILL PASS UNLESS BOARD OF HEALTH OETERMINES THAT THE SYSTEM IS NOT WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: 1) Cesspool or prkvy is within SO feet of a surface water LrCr Cesspool or privy is within 50 feet of a bordering vegetated wetland or a ,all m.arsn SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPRC R .AT•: THE SYSTEM IS FUN'CTIONINC IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND S�,F:''� EN'VIRON'MENT ,(JS� The system has a sept-c tank and soil absorption system (SAS) and the SAS is w (r-in !_ ec = tributary to a surace water supply. �; Tne system nas a septic tank and soil absorption system and the SAS is within a lore : o' 4' Tne system nas a septic tank and soil absorption system and the SAS iS ­!h1n 50 tee'. c' The system has a septic tank and soil absorption system and the SAS is less than '0C 'Prl =_ . . .. private water supply well, unless a well water analyses for col,form oaoer,a ane c,gj" the well is Iree from pollution from that Iacthry and the presence of ammonia n,;roger In:: less than 5 pprn Method used to determine distance (approximation no: .,: 3) OTHER SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) # 1160 Property Address:Unit 1A Arbor Terrace Condo' s Phinneys Lane Hyannis,Mass . Owner: David HIrsch Date of Inspection: 4/1 7/98 DI SYSTEM FAILS: You must indicate er, er "Yes" or "No" as to each of the following: /VLF I have determined that the system violates one or more of the following failure criteria as defined to 310 C»R 15.303 The Dash for this determination is identified below. The Board of Health should be contacted to determine what will be necessa y to correc the failure. Yes No Backup of sewage into facility or system component due to an 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 cloggec SAS o- cesspool, Static liquid level in the h l�stribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in casspQQ4 is less than 6" below invert or available volume is less than 112 day flo,^. Required pumping more than a times in the last year NOT due to clogged or obstructed pipe($). 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 supp: 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 wl:n no acceptable water quality analysis. If the well has been analyzed to be acceptable, anach copy of well water analysis -or coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (large System) and the system is a significant tnrea( to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply J� the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone 11 of a public water supply well) The owner or operator of any such system shall 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 (rrrviaed 04/75/97) ➢ag• 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Unit 1 A Arbor Terrace Condo' s Phin0neys Lane Hyannis,Mass . Owner: David Hirsch. Date of Inspection:4/1 7/98 Check if the following have bee;, done: You must indicate either "Yes" or "No" as to each of the following: 1 No / Pumping information was provided by the owner, occupant, or Board of Health. �1 None of the system components have been pumped for at least two weeks and the system has been receiving norm i flow rates during that period. Large volumes of water have not been introduced into the system recently .or / as part of this inspection. !� As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components, t4uding the Soil Absorption System, have been located on the site. _ The septic tar:k manholes were uncovered, opened, and the interior of the septic tank was inspected for condition o: baffles or :ee:, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. — The size and locrt)n of the Soil Absorption System on the site has been determined based on: The iacilry o-vner (and occupants, if djfferent from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System Existing information. Ex. Plan at B.O.H. Determinud i:i the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unaccepta:)l,2, O 5.302(3)(b)) (revised 04/25/97) Page 4 of 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION 60 Propene Address: Unit 1A Arbor Terrace Condo' s Phinneys Lane Hyannis,Mass . O..ner: David Hirsch. Dare of Inspection: 4/17/98 FLOW CONDITIONS RESIDENTIAL: Design floes jpI.D g p.d./bedroom for S.A.S. ',umber of bedrooms. /Z lumber of current residents Caroage gender (des or no) F Launcry connected to system (yes or no) Seasonal use Ives or no;A >J aie meter readings, if available (last two (2) year usage (gpol:� /lylll�� Use -1*6 Sump Pump (yes or no) �/,J �; � - l��Fr'1 T ohs c�� � ,as; tale of occ::panc-' y-�1-�1� )7q A 16 COM."ERCIAUINDUSTRIAL: �QZId� ti T w of establ shment Design floe z114 allons./day Crease trap present. (yes or no)212V nousinal Waste Holding Tank present :yes or no) ,,on sanitan ,asle discharged to the Tale > system (yes or no)14 ",a:er meter readings, if available Las: oate of occupan A OTHER: ;Describe, Ali, .a}, die o! occuoancl „ GENERAL INFORMATION PL."PING RECORDS and source of info-matron Svstem pumped as pan of inspecion Ives or no),-9 c-O If yes, volume pumped gallons Reason for pumping TYPE OF SYSTEM �eptic tank/distribution boVsoil absorption system Single cesspool �f>C) Overflow cesspool 1 Privy Shared system (yes or no) (if yes, anach previous inspection records, if any) Id 2 I/A Technology etc. Copy of up to date contract Other s- APPROXIhtATE AGE of all components, date installed (if known) and soiree of information k7 -'Y'o r� Se»age odors detected when arriving at the site: (yes or no)/L� ;r•v:••C 0�/IS/57) P49. 5 of 10 SUBSURFACE SEsNAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) # 1160 Property Address: Unit 1 A Arbor Terrace Condo s Phinneys Lane Hyannis,Mass . Oh ner: David Hirsch Date of Inspection: 4/1 7/98 BUILDING SEWER: .ocafe on site plan. Deptn below grade y� —atenal of construcion: cast iron /40PVC _ other (explain) Distance irom p/!Vale water supply well or suction line 107 74'" D�a,me!er COm`:,ents lcond�tion of joints, renting, evidence of leakage, e}c.l�^ . I.L SEPTIC TANK:-, !oca;e on site plant [1 Dep!n Deco- grade -.•a!er�al of construction: concrete _metal _Fiberglass _Polyethylene _other(explain) u tank is metal, list age Is age confirmed by Certii,cate of Compliance A)A(Yes/No) Dimensions 114 /6�q Slucge depth D,stance from to sludge to bonom of outlet tee or baffle: Scum (nickness l),0We_ D stance from top of scum to top of outlet tee or baffle:,/r>4e1C_ D,stance from bonom of scum to bonom of outlet to or baffle:�^_ f� r-.o, dimensions were determined. C Comments recommendat,on for pumping, conditi of inlet.-ad outlet tees or afile. , dept of liquid level in relation to outlet inveri, strucura nlegnr evidence of leakage, etc.) V l" y�G -(Jr CT CREASE TRAP:�r9x ' ,oca:e on site plan; Dep!n below grade IGV� ti�,atenal of con struct ion:2Mconcrete,(l meta I/t F berglasW& Polyethylene (4other(explain) ti'� Dimensions: A4 Scum thickness, IVI D,s;ance from top of scum to top of outlet tee or baffle:.z/g D,sance from bonom of scum to bottom of outlet tee or baffle:�i f� Date of last pumping Comments recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structura. ntegriry, evidence of leakage, etc) 1 se_ U Iry is rUeT iv�Sral° ' i rr.--d P•g• 6 of 10 f _ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR.tis PART C SYSTEM INFORMATION (continued) #>!1 1 6 0 Properly Address: Unit 1 A Arbor Terrace Condo' s Phinneys Lane Hyannis,Mass . Owner: David Hirsch Date of Inspection:4/1 8/98 SOIL ABSORPTION SYSTEM (SAS):,/-2-41—,�.4.4 "'" ;locate on site plan, if possible; excavation not required, but may be approximated by non•inuusjve methods) If not determined to be present, explain: Type leaching pits, number:, a leaching chambers, number: leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimeDons: (' overflow cesspool, number _��{" Alternative system: ,(3 Name of Technology: Comments (n to condinonnnof soil, signs of hydraulic failure, level of ponding, co�n7dit,on of vegetation, etc.) ----- r - .� r .tom S /ONff✓� _ — CESSPOOLS: Alc;,Ve- (locate on site plan) Number and configuration: Q r Depth-top of liquid to inlet inven: A14 Depth of solids layer: &2 Depth of scum layer: AIX Dimensions of cesspool: AIW Materials of construeion: 422j Indication of groundwater: X2 inflow (cesspool must be pumped as pan of inspectjon) _ Comments. (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Q >S D'Gs Q— — — 1, — -- PRIVY: jQwe— floca(e on site plan) Materials of constr�uction: I&X Dimensions Depth of solids Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) 1[•v1�•d 0�/15/97) D•g• B of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Prope", Address:Unit 1 A Arbor Terrace Condo' s Ai1nneys Lane HYANNIS,Mass, 0,ne!. . David Hirsch. Date ct inspect-on: 4/18/98 TICr i OR HOLDING TArr'KaG1/Y.(Tank must be pumped prw to, or a, time. of nSpeC� Onl uoca:e Gn s.:e plan) Dep:n ;,elo, grade ,VA Ma:er,a; o' constfvctronA.),4concreted 4metal VAFiberglass,44Polyelhyiene 1Ljother(explain) U i D,menS,ons / Capac-"/ gdllOnS Des,gn i,o., 9 gallons day Alarm, :e.el V_ Alarm to working order/A Yes.IVA Nu Dale o' Dre"Ovs pumping Commen:s tconco,c;n o: -nlet tee, condition Of alarm and float swathes, etc ) DiSTRi3 ;TiON BOX.. �o<j:e s :e plan) De.:- _.-d level above outlet -()Yen iV(7 C o—e-:5 (no, I level and distribution is equal, evidence of soh,J5 ca(ryover, evidence of leakage into or os(( cf Do.. e.; , �STrl no' VJ�� h�4S in 1.A djjr=e c) !� Ors - -- PUMP CHAI-+BER: etdwe tiocxc cn s,:e plan) P,mcs ,r , o(king order (Yes or No) /VA Atarrns , .,ork-ng order (Yes or No)_Zy Comm.en:s note :or c.,•on of pump chambe(, condition of pumps and appunenance5, etc.) tr. ;: C :q/75/S)) P.q. I of 10 SUBSURFACE SEWACE DISPOSAL SYSTEM INSPECTION FOR.tis PART C SYSTEM INFORMATION (continued) # 1160 Properly Acdress: Unit 1 A Arbor Terrace Condo' s Phinneys Lane Hyannis,Mass . 0»ner. David Hirsch Dale of Insaechon: 4/1 7/98 SKETCH OF SEWAGE DISPOSAL SYSTEM: -•:tune ties to at least two permanent references landmarks or benchmarks Io,-ale all wells within 100' (locate where public water supply comes into house) i p 4 ---- �j I (r•�:..: ;�/:S/971 P.9. 9 of 10 r SUBSURFACE SEWAGE DISF SYSTE•ti1 INSPECTION FOR o SYSTEM INFOI tcontinued) #1160 Proper'.. .;--ress Arbor Terrace Condo' s Unit 1 A Phinneys Lane Hyannis,Mass . o ne' David Hirsch Date of insoectjon. 4/1 7/98 D 1V �n t eptn to C!oundwater Feet Please inC;tale all the methods used to determine H,gh Groundwa!V' Ele.a.jon: Cc:amK from Design Plans on record �C-/ sera! on of Sue (Abuning property, bservatIon hole, basernenr sjmp eIc l r•e•.e.,,.•�ne ii from local conditions .,:n local Board of healln E'.N-A Maps e:. D-; -. ),ng records Iocal exca�a:ors. 'nstaller; e SCS Data Desc, oe .o.:r own words how you established the H,gh Grounc�,w,rcr: eval,on. Must be compleled' Used Water Contours .Map. Gahrety & Miller Model 12/16/94 .r� n rv—r— r•r. rrr.n rnrrRr.re-r.rr.r...�+-r-.vet:m��r-ns-•+t,t*.a•me+.rr- - — *rr�.r--c. n*ra rr.-r-.�--r— I TOWN OF Rarnctab1 a BOARD OF HEALTH S011SI1RFACR SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART U CFwrIFICA'rIUN •'\� �'•••-••••T•'-. •-�.II•••�T.T.•'RI'R.tTITTSrT/T.TTT'.-•.'1"'STR1�TTt1RR�'Fr1 R11111TRRTSTO-11T�.+�:�r-r�.p•._. .�. -TYPE OR PRINT CI.EARL1'- PROPERTY INSPECTED # 1160 Phinneys Lane STREET ADDRESS Unit 1A Arbor Terrace Condo''�s HYannis,Mass . ASSESSORS MAP , BLOCK AND PARCEL # � � OWNER' s NAME David Hirsch PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber. & Soff Inc. COMPANY ADDRESS Box 66 Centerville,Mass. 02632 Street Town or Clty Stat• CIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 790 - 1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system nt this address and that the inrorination reported is true , accurate , and complete as of the time of .-inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : _zSys teui PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public heallll or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* The inspection wllicll I have conducted has found that the system fails to Protect the E)tlblic health and the environment in accordance with 'title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature Date One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the 130ARD OF IIIiAL1'll. • If the inspection FAILED, the owner or "operator shall upgrade the eyatem within one year of the date of the inspection , unless allowed or required otherwise as provided in 310 CmR 15 . 305 , partd . doc w � J) S byv 3'�t THE COMMONWEALTH[ OF MASSA.CHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15 .340 and Section 13 of Chapter 21 A of the General Laws. Issued by The Department of Environmental Protection. June 8. 1995 Ac[inx Director of the L iun of Water Pollution Control — _ J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A h_ 9 CERTIFICATION 1160 Phinneys Lane, Unit 413 AD Property Address:eentep4ge,Ma �y a(//�► /V nJ!S Address of Owner: (if different) 10 Date of Inspection: 13 April, 1999 iSg, �99g Inspected by: James Holler I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (31 4 Company Name: Holler & Son Construction LLC Mailing Address: P. O. Box 702, Marstons Mills, Ma 02648 Telephone: (508) 420-0280 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: ®Passes ❑Conditionally Passes ❑Needs Further Evaluation by the Local Approving Authority ❑Fails Inspectors SignaturUst Zoo Date: 13 The system inspector shall 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) SYSTEM 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: Comments: B) SYSTEM CONDITIONALLY PASSES: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health, will pass. Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not. ❑The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or extiltration,or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (Continued) Property Address:1160 Phinneys Lane,Unit 4B Owner:Saul&Esther Brecker Date of Inspection: 13 April, 1999 B) SYSTEM CONDITIONALLY 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). Describe observations: ❑ broken pipc(s)are replaced ❑ obstruction is removed ❑distribution box is leveled 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 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 the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT. ❑Cesspool or privy is within 50 feet of a surface water ❑Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. ❑ The system has a septic tank and soil absorption system and the SAS is with 50 feet of a private water supply well. ❑The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or Icss than 5 ppnt. Method used to determine distance (approximation not valid). 3) OTHER SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1160 Phinneys Lane,Unit 4B Owner:Saul&Esther Brecker Date of Inspection: 13 April, 1999 D) SYSTEM FAILS You must indicate either"Yes"or"No"as to each of the following: ❑I have detenmined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303.The basis for this determination is identified below. The Board of Health should be contacted to 15.304. detennine what will be necessary to correct the failure. Yes No ❑ ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or Cesspool. ❑ ❑ Discharge or ponding of eflluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. ❑ ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. ❑ ❑ Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow. ❑ ❑ Required pumping more than 4 times in the last year not due to clogged or obstructed pipe(s). Number of times pumped ❑ ❑ Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. ❑ ❑ Any portion of a cesspool or privy is with 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 with 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 colifonn bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: You must indicate either "Yes"or"No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: ❑ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the enviromnent because one or more of the following conditions exist: Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of 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. The owner or operator 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. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1 160 Phinueys Lane,Unit 4B Owner:Saul&Esther Brecker Date of Lispection: 13 April, 1999 Check if the following have been done: You must indicate either"Yes"or"No"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner,occupant,or Board of Health. ® ❑ 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. ® ❑ As built plans have been obtained and examined. Note if they are not available with N/A. ® ❑ The facility or dwelling was inspected for signs of sewage back-up. ® ❑ The system does not receive non-sanitary or industrial waste flow. ® ❑ The site was inspected for signs of breakout. ® ❑ All system components,excluding the Soil Absorption System,have been located on the site. ® ❑ The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of battles or tees,material of constriction,dimensions,depth of liquid,depth of sludge,depth of scum. The size and location or the Soil Absorption System on the site has been determined based on: ❑ ® The facility owner(and occupants,if ditTerent from owner)were provided with information on the proper maintenance of Sub-Surface Disposal System. ® ❑ Existing information,Ex.Plan at BOH. ® ❑ Detennined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [15.302(3)(b)] SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property address: 1 160 Phinneys Lane,Unit 413 Owner:Saul&Esther Brecker Date of Inspection: 13 April, 1999 FLOW CONDITIONS RESIDENTIAL Design(low: 110 gpd/bedroom for SAS Number of bedrooms 2 Number of current residents:2 Garbage Grinder:No Laundry conunected to system:Yes Seasonal use:No Water meter readings,if available (last 2 years usage in gpd):Not Available Sump pump:No Last date of occupancy:Current COMMERCIAL /INDUSTRIAL Type of establishment Design flow: gpd Grease trap present: Industrial Waste holding tank present: Non-sanitary waste discharged to the Title 5 system Water meter readings,if available Last dale of occupancy OTHER: (describe) GENERAL INFORMATION PUMPING RECORDS and source Ace Septic Service System pumped as part of inspection No Volume pumped:N/A Reason forpumping:N/A TYPE OF SYSTEM ®Septic tank/distribution box/soil absorption system ❑ Single cesspool ❑Overflow cesspool ❑Privy ®Shared system(y/n)(if yes,attach previous inspection records,if any) ❑UA Technology etc.Copy of up to date contract? Other System services 4 condominiums and is pumped semi-annually APPROXIMATE AGE of all components,date installed(if known)and source of information: 1983 Sewer odors detected when arriving at the site:No SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (Continued) Property Address: 1160 Phinneys Lane,Unit 413 Owner:Saul&Esther Brecker Date of inspection: 13 April, 1999 BUILDING SEWER (Locate on site plan) Depth below grade 20" Material of construction❑Cast Iron®40 PVC❑other Distance from private water supply well or suction line>40' Diameter 4" Comments:(condition of joints,venting,evidence of leakage,etc. ) SEPTIC TANK (locate on site plan) Depth below grade 20" Material of construction®concrete❑ metal ❑Fiberglass❑Polyethylene❑other If metal list age is age confinned by certificate of compliance Dimensions:2000 Gallon Sludge depth:3" Distance from top of sludge to bottom of tee or baffle 41" Scum thickness None Distance from top of sctun to top of outlet tee or baffle Comments: GREASE TRAP (locate on site plan) Depth below grade Material of construction❑concrete❑metal❑Fiberglass❑Polyethylene❑other Dimensions Scum thickness Distance from top of scum to top of outlet tee or baffle Date of last pumping Conunents: (recoumnendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leak,etc.) SUBSURFACEi SEWAGE DISPOSAL SYSTEM INSPECTION FORM i PART C SYSTEM INFORMATION (Continued) Property Address: 1160 Phumeys Lane,Unit 413 Owner:Saul&Esther Brecker Date of Inspection: 13 April, 1999 TIGHT OR HOLDING TANK: ❑(Tank must be pumped prior to,or at time,of inspection) (locate on site plan) Depth below grade Material of construction: ❑concrete❑metal❑Fiberglass❑Polyethylene❑other(explain) Dimensions: Capacity: gallons Design flow: GPD Alarm level: Alarm working?❑yes❑no Date of previous pumping Cormnents: (condition of inlet tee,condition of alarm and float switches,etc. ) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert:0" Comments(note.if level,and distribution,is equal,evidence of leaks or solids carryover,etc. ) PUMP CHAMBER: ❑ (locate on site plan) i i Pumps in working order: (yes or no) Alarms in working order:(yes or no) Cormnents:,(note condition of pump chamber,pumps,and appurtenances,etc.) i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(Continued) Property Address: 1160 Phinneys Lane,Unit 4B Owner:Saul&Esther Brecker Date of hispection: 13 April, 1999 SOIL ABSORPTION SYSTEM: (SAS)ER (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,nwnber 2,(1000 gallon) leaching chambers,number leaching galleries,number leaching trenches,number&length leaching fields,number&dimensions overflow cesspool,number: Alternative system: Name of technology Comments:(note condition of soil,signs of hydraulic failure,ponding,vegetation,etc. ) 0'r-d-1 wAr&2 L,9V L +'/z Fi;;&r BMofLJ rrJciT �i!'E PIT 42- tt 1112_ Lk 41It CESSPOOLS: ❑ (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of sewn layer Dimensions of cesspool Material of construction Indication of ground water inflow(must be pumped as part of inspection) Continents:(note condition of soil,signs of hydraulic failure,ponding,and vegetation,etc.) PRIVY❑ (locate on site plan) Materials of construction: Dimensions Depth of solids Comments:(note condition of soil,signs of hydraulic failure,ponding,vegetation etc.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(Continued) Property Address: 1160 Phinneys Lane,Unit 413 Owner:Saul&Esther Brecker Date of Inspection: 13 April, 1999 SKETCH OF SEWAGE DISPOSAL SYSTEM Include ties to at least two permanent references,or benclunarks,locate wells within 100'and where public water supply enters house. 2J� f) Ll Ai � t� a S1 V2 -d i U AS °' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.C SYSTEM INFORMATION (Continued) Property Address: 1160 Phinneys Lane,Unit 4B Owner: Saul&Esther Brecker Date of Inspection: 13 April, 1999 Depth to Groundwater 22 feet Please indicate all the methods used to determine High Groundwater Elevation: ❑ observed from design plans on record ❑ observation of site(abutting property,observation hole,basement sump) ❑ determine it from local conditions ❑ check with local Board of Health ❑ check FEMA maps ❑ check pumping records ❑ check local excavators,installers ® use USGS data Describe in your own works how you established the High Groundwater Elevation. (Must be completed) F/D MPF&-t- M-P7*b NT Imo 0 1 w. O�cc� 7`C rc tl C2 �Z BORTOLOTTI CONSTRUCTION,INC. ftfalVED 765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 - NOV 508-771-9399 508-428-8926 FAX: 508-428-9399 1 5 j990 ` Moir SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO �t lftr PART A CERTIFICATION ,� Properly Address: 2 Q� Date of Inspection: /- - Inspector' Name: -z �j ,/,[ Owner's Name and Address: -/ o C ,Z CERTIFICATION STATEMENT! I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of inspection.The inspection was per- formed based on my training and experience in the proper function and maintenance of on-site sewage disposal stems. The System: Passes Conditionally Passes Needs FurtheLrvlua,,tion By the Local Aproving Authority Fails Inspector's Signature: Date:_ 41Z311r__ The System Inspector shall submit a copy of this inspection report to the Approving authority within thir- ty(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! A)SYSTEM 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; One or more system components need to be replaced or repaired. The system,upon comple- tion of the replacement or repair,passes inspection. Indicate yes,nor,or not determined(Y,N,OR ND). Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is.metal,cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup 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): - 1 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) - Broken pipe(s)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 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 the public health,safety and the environment. 1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 Feet of a surface water Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh. 2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER s SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 Feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is with a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. The system has a septic tatilt and soil absorption system and is less than 100 Feet but 50 Feet or more from a private water supply well,unless a well water analysis for colifonn bacteria and volatile organic compounds indicates that the well is free from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D)SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent 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 clog- ged SAS or cesspool. Liquid depth in cesspool is less than G"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 -2- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 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 SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a 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 The system is located in a nitrogen sensitive area Interim Wellhead Protection Area (IWPA)or a mapped Zone Il of a public water supply well. The owner or operator 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. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: Pumping information was requested of the owner,occupant,and Board of Health. None of the system components have been pumped for adeast 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. As-built plans have been obtained and examined. Note if they are not available with N/A. JThe facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. e­All system components,excluding the Soil Absorption System,have been located on site. i-- The septic tank manholes were uncovered,opened,and the interior of the septic tank was in- spected for condition of baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. -3- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) C,--"The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS U�1 RFSLDENTLALo loe,( � ��uy%7 Design Flow: ZZ© gallons Number of Bedrooms: Z Number of Current Residents: / Garbage Grinder:_ Laundry Connected To System:_ Seasonal Use: X10 Water Meter Readings, if available: Last Date of Occupancy: C�Jh'2NT� COMMERCLAJAND 1 T IAL: Type of Establishment: Design Flow: gallons/day Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: OTHER: Describe) A Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information:, System Pumped as part of inspection: VO If yes,volume pumped: gallons Reason for pumping: TYP. OF SYSTEM: Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records,if any) Other(explain): APPROXIMATE AGE of all mponents,date instal (if known)and source of information: --'o �d � 4 I � © yl Sewage odors detected when arriving at the site: -4- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: Depth below grade . Material of Construction: V concrete metal FRP_Other (explain) Dimisions:_ /Z,SX XS- Sludge Depth: Scum Thickness: Distance from top of sludge to bottom of outlet tee or baffle:_ 34/' Distance from bottom of scum to bottom of outlet tee or baffle: /Z. Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,evidence of leakage,etc.) �S cn n(Q 0 qa G G l's �. qlp / ,r I f te 'A �i GREASE TRAP: Depth Below Grade: Material of Construction: concrete metal FRP Other (explain) — — — Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.) TIGHT OR HOLDING TANK:_Zzo Depth Below Grade: Material of Construction:—concrete metal FRP Other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm Level: Comments: (condition of inlet tee,condition of alarm and float switches,etc:) DISTRIBUTION BOX: --,/— Depth of liquid level above outlet invert: / � Comments: (note if level and distribution is equal,eviddWce of solids c rryover,evidence of leaks into or o of box,etc. PUMP CHAMBER: Pump is in working order: Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.)- -5- `y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM(SAS):_L/ (Locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: ,hype Leaching pits,number: Leaching chambers, number: Leaching galleries,number: Leaching trenches,number, length: Leaching fields,number,dimensions: j. Overflow cesspool,number: Comments: (note condition of soil, signs of hydraulic failure level of ponding,condition of vegetation; etc.) re 0 /6)00 A-_ _ /'P q i p(e r f A'z ii D l' w� CESSPOOLS: Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of Cesspool: `i Materials of construction: Indication of groundwater: k"•'' Inflow(cesspool must be pumped as part of inspection) <t Comments: (note condition of soilk, signs of hydraulic failure, level of ponding,condition of vegetation, q etc.) f a" PRIVY: Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) a,l lwf -G -t • I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) i SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within 106 Feet. I 0? i • DEPTH TO GROUNDWATER: Depth to groundwater: Method of Determination r App ximation: �'��A' G/ J?'Iff1 �!. �e •i d�`1 /or j B -7- !!(gyp Phinn ty`s LQzq TOWN OF BA STABLE +' LOCAfIONJ r c el 0^)Vj SEWAGE# VILLAGE ., SSESSOR'S MAP&PARCEL 2773— Fll- J6JUOA ) INSTALLER'S OL tI1V1Vr O. 4yl e* I/ZJ 40, / SEPTIC TANK CAPACITY o?000 llr w t- VCW ►V t o LEACHING FACILITY:(type) 0 AM lh qT toAa (size) /4,37S )r S-D NO.OF BEDROOMS OWNER Q(Lbor 1-Cf(Ace e onj a 41soc�?4-�-i�� PERMIT DATE: l( Z 3 Zoo COMPLIANCE DATE: ( off t Zc Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility wo /2 Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) ' Feet FURNISHED BY C 4P4-V i GLR �K'fI P Z'S BS LCC $ =f.zib' A9L> hr s t 00 co a.W .y 3 C i i TOWN OF BBARNSTABLE LOCATION/ZC���I�nn,��xs ion P- Ar7Au 1'76Pi`rzr SEWAGE# V 1,013 AS ASSESS 'S MAP&LL T G 9'9-do 0 __ � r'' NAME&PHONE NO�O r-10/D�i ��'J 'T��- SEPTIC TANK CAPACITY(�26GY) a?/ 5eaV-`G � 20X LEACHING FACILITY: (type) f S �� (size) NO.OF BEDROOMS BUILDEROWNER �� 9"-/�G'J PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: i Maximum Adjusted Groundwaier 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) /�//i� Feet Edge ofi Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching c' ty) / Feet Furnished byar+/ok J'7�1C���i�Jn, �lG I 3 uo O . b TOWN OF BARNSTABLE LOCATION 1140 " W A-21•FY -414'1 SEWAGE # VILLAGE 'L ASSESSOR'S MAP & LOT!13" ? - fir' INSTALLER'S NAME&PHONE NO. A O SEPTIC TANK CAPACITY /e£ PZ,4 C ��k LEACHING FACILITY: (type) (size) 0.OF BEDROOMS BUILDER OR OWNER IfQQ1f I£�� f PERMITDATE: l0 D 3 A COMPLIANCE DATE:�D 3 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by " 0 m w _ o 4 r' - a TOWN OF BARNSTABLE fi=)CATION SEWAGE # VILLAGE ASSESSOR'S MAP & LOT IN5Pfc7a-/es �1:ER'S NAME&PHONE NO. SEPTIC TANK CAPACITY .S'£.,,07i c I `LEACHING FACILITY: (type) (size) ?n. OF BEDROOMS BUILDER OR OWNER 7PEI MIT'DATE: CGNWt E DATE: I �N.SP£cTio�- Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 0 Q O r* ® O T 7 M� V _J Fu y? iqr �,l Te,&4CL. GoA o's (3UU'''11;ar T WN OF BARNSTABL)t 3 a. ;�TION rr(OO PA04'u- /4u— SEWAGE # r Y LI:AGE ASSESSOR'S MAP & LOT INSTAL I ER'S NAME&PHONE NO. SEPTIC TANK CAPACITY SOUL? LEACHING FACILITY: (type) � f— W l" (size) IM NO. OF BEDROOMS_ BUILDER OR OWNER Ar�o/ ///au- G Dn�D ASS, PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximurn Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachi facility) Feet Furnished!by T/1 SO t u 04 _ FD/ 37 � 3 ga �� I� b � a 3 Fran- A � 6.,,4.W s TOWN OF BARNSTABLE SEWAGE # TILLAGE_e!2� O�i1_� / �-� ASSESSOR'S MAP & LOT i INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) �2—Z!?.�4F,.�I t�` a� (size) C� i NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: I Separation Distance Between the: Maxiutum 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 a 'st within 300 f t of leaching aci ' ) Feet Furnished ��wo/yam ' GJ U t No. d�� �. 0 Fee 60, THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: . PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS es 4pfltation for M1sp08al bpstrm Construttion VPrmit Application for a Permit to Construct( ) Repair(,)Q Upgrade( ) Abandon( ) ❑Complete System pndividual Components Location Address or Lot No. //(o p P�, I �,q� Owner's Name,Address,and Tel.No. Assessor's Map/Parcel a-73 1,311,Installer's Name,Address,and,Tel.No..J_ (�.�Z/—!-8 7-7, Designer's Name,Addr ss,and Tel.No. C �d� -t GSA l�-E &x go &,, U, 114 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) ,0 0<,- Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site;sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Sig6L-, _ Date �--7 o Z o r'"L. Application Approved by Date 's . e Application Disapproved by _ Date for the following reasons Permit No._ 2 U 2—j aLip Date Issued „�."+.s.fir..y.tr.rw.- '4^-•y!'+'n.;,-�epA,«ti,.r- eA„�' .•cyy. SL�...-.—.--.-..-.-...-.-...�+v----�.-�.. .-a---......r.- �--, ,-..-,M,..,,,.e•-ygrr,+=.. r Fee THE COMMO,:N ALTH OF MASSACHUSETTS Entered in computer: 'PUBLIC HEALTH DIVISION -TOWN-OF BARNiSTABLE, MASSACHUSETTS ft hratio, for Misoosal 60stem Construction Permit Application for a Perm tt o C nstruct( ) Repair(jC) Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address Or Lot,No. /%100 Pti j (,/Ile Owner's Name,Address,and Tel.No. r i Assessor's Ma /Parcel + t ..,,/� P a 7 3 D 4.5 �^r,r. �'i'c'/�l r Installer's Name,Address,and Tel.No. '7� Designer's Name,Address,and Tel.No. s' C"4 6-4 ),'scC L Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder'( ) ,w Other Type of Building No.of Persons Showers( Cafeteria( ) _ Other Fixtures Design Flow(min.required) ; I-gpd Itsign flow provided d gP Plan Date % ( ;`( ' ( aN mber of sheets Revision Date v $ Title x3 Size of Septic Tank Type of S.A.S. -4, Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: 0 1� }� Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions.of Title 5 of the Environmental Code and not to place the system in operation until a Certificate ofi , ” Compliance has been issued by this Boar/d�of Health. Sigpe'd 11 _ c Date 7 71 O)�Z' s\ Application Approved by (l I Date Application Disapproved by Date for the following reasons t Permit No. 2 0 '2 "IU Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS V y Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded(. ) Abandoned at b a 1'H' .�.t,S l.� ai�a a a has been constructed in accordance with the provisions of Title 5 and the for}Disposal System Construction Permit No.2 012—1 j� dated Installer (�, 0II& .►+(� �:'1-h_xy'o Designer -6 JA r #bedrooms Approved design flow P/J/_ gpd The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date 1'' Inspector ---'No.---� / Z — /.��-^-----�- ----_._ _-----�-_-�-----------------=-------=-r---==--_--_---_=----------=Fee THE COMMONWEALTH OF MASSACHUSETTS . PUBLIC HEALTH DIVISION.-BARNSTABLE,MASSACHUSETTS MSPOsal *pstrm Construction 3permit Permission is hereby granted to Construct( ) Repair O Upgrade( ) Abandon( ) System located at ` f0 b ��+�l t2r S -/a'H.t nl L)a 4 and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with r i Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit! Date Approved by • � U No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS es 2ppliLation for Disposal *pstem Construction Permit Application for a Permit to Construct( ) Repair()4 Upgrade( ) Abandon( ) ❑Complete System dividual Components Location Address or Lot No. i I4v p 10y7,h"'s L, � Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 2-73- D-'rq ob Pnhr^ Co rz10 ►f�5 Installer's Name,Address,and Tel.No. q 't fS'? 7") Designer's Name,Address,and Tel.No. CqpZW,J,�'h{t��l�sej jlo 150x Zco) Ce.�i-o'�((c . Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: L�- Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date 'J�' 7 -Z t.r Z- Application Approved by M N Date Application Disapproved by Date for the following reasons Permit No. ;)_0( 2 - �,� Date Issued - -7-2 0 12- No. Fee /Ulf THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 91JIMC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS es ftpfiration for lDisposal *pstem Construction permit Application for a Permifto-Co truAA( ) Repair(o Upgrade( ) Abandon( ) ❑Complete System I dividual Components Location Address or Lot No�N-&-6Ph,hK el L i4 Owner's Name,Address,and Tel.No. 5 1 A.2,3,D.2 '!-Ellvc4(e. Assessor'sMap/Parcel 3- oSs � f^nri _ - Innstaller's Name,Address,and Tel.No. '? 7) Designer's Name,Address,and Tel.No. C Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date _-. -- Title Size of Septic Tank Type of S.A.S. E t Description of Soil Nature of Repairs or Alterations(Answer when applicable) i L-e.Ptw 77 Date last inspected: so ( t f Agreement: r ,The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. � Signed V\ ak Date - 7 -Z.cz.r L Application Approved by I V�1 /j ro Date Application Disapproved by Date for the following reasons -� Permit No. ! 2. - / / Date Issued r— 7-2 a/2 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Comphante THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( _ Upgraded( ) Abandoned( )by ' Cq o,, ,L E L r n .l e> (..1,.C at 1 l to v Dl„.,n ak S t z+.,c' 3 td, has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. .7 0,I2_J l dated "7-� }� Installer C d,l-,e w &D- j 0-.''K ti L L< Designer 11 #bedrooms Approved design flow A A t�i gpd The issuance of this permit shall not be construed as a guarantee that the system will fiutcfon a§!designed r ( ! _ Date ,' �. Inspector ,.' �. _ •�' : --- No. -)u 13 - r �a -_ 3� Fee �THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION 71 BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction J)trmit Permission is hereby granted to Construct( ) Repair(�() Upgrade( ) Abandon( ) System located at I 1 (o c7 ?Lt,Vk r-c,. J and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date -2- Approved by—`)-)(, I(�,� Page: 1 CERTIFICATE OF ANALYSIS `yrs^ tip;` Barnstable County Health Laboratory Report Prepared For: Report Dated: 2/24/2004 Hamel,Elaine Order Number: G0424236 Elaine Hamel 1160 Phinneys Ln. Unit 2D Centerville, MA 02632 Laboratory ID#: 0424236-01 Description: Water-Drinking water Sample#: 242361 Sampline Location: 1160 Phinneys Ln Centerville Collected 2/17/2004 Collected by: E Hamel Received: 2/17/2004 GL Routine RL 21241°4 ITEM RESULT UNITS Mgt MCL Method# Tested LAB: IC Lab / Nitrates 2.6 mg/L 0.1 10 EPA 300.0 2/18/2004 LAB: Metals Copper . .<0.1 : . .. -mg/L ..o.t - 1.3 - SM 3111B - 2/18/2004 - Iron 0.1 mg/L 0.1 0.3 SM 3111B 2/18/2004 Sodium 3Q� mg/L 1.0 20 SM 3111B 2/18/2004 LAB: Microbiology Total Coliform A P/A 0 Absent 307 2/17/2004 LAB: Physical Chemistry Conductance 240 umohs/cm 1 EPA 120.1 2/17/2004 PH 7.6 pH-units 0 EPA 150.1 2/17/2004 `Note: -Sodium level above the average.Those on low sodium diet may wish to contact physician.. Approved By: (L Director) a i j Superior Court House, PO. Box 427, Barnstable, MA 02630. Ph: 508-375-6605 L0C'A'tIVN SEWAGE ; PERMIT NO. :S" -44.1 �� �ea� y VILLAGE INSTkLLER'S NAME i ADDRESS �. ft 1CIG G U I L D E R OR OEM ER LQ DA, TE PERMIT ISSUED DATE C0-MPLIANCE ISSUED " f CLi R!J ou-r �v� - . No.. .............. Fx$............._............... THE COMMONWEALTH OF MASSACHUSETTS ;t BOAR® OF HEALTHr � sa tt �9jX4........ . OF........- h. . Appliration for Diipuiial Works Tomitrnrtion Permit Application is hereby made-for a Permit to Construct ("XIL or Repair ( ) an Individual Sewage Disposal'; System at: � Location-Address or t No. wnez 7 Address a "1 .................J_ .................................. -------....-••---•-----------------..........•-`--•-------•-•--•......--------------------•-Address Type of Building Size Lot... _0 .(,.Sq. feet Dwelling—No. of Bedrooms........(f..............................Expansion Attic ( ) Garbage Grinder ( ) Other—Type .of Building No. of ersons___.____..__.________________ Showers — P� YP g ---------------------------- P ( ) Cafeteria ( ) Q' Other fixtures ........................._............................................................................................................................ W Design. Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacit3242'Q_gallons Length---------------- Width................ Diameter_____________.__ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.---,-.:?........... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed ",<.......................... Date____ ...... Test Pit No. l._ _ .._..minutes per inch Depth of Test Pit___ _._ Depth to ground water-------' -_______- fi, Test Pit No. 2__4__2....minutes per inch Depth of Test Pit--- Depth to ground water........ -_______ �+ -----------••--••------ -------•----------------------------------------------------------- O Description of Soil----- - 1.....� "_� ---- ------ -- x ---------•------•••••-•-•-•--•--•--•-•---•----------6---=`1Q4_.�-----�-J. •"- ice..... �c� .F•� � ----------------=---------------------------------- � . �� G �a U - ,�' = Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with o, the provisions''of HiTf,% 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beep,issiAed.,by the board of health. Signed .---•--•-----•---•-•-----•-••-------•-••-•- ............................- Date Application Approved By-••r !. ....... • ...................... ....... ��-............ ate Application Disapproved for the following reasons:--------- •--------•-•-••-•-•--•----•••---•----------•••••----•-•••---•--------•-----------•-------••--------- f - t Date Perms No............... - J Issued - � � � � Date W No.... _�.. ........° THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH fQlc1.. ................oF......... Applira#ion for Mivasal Workii Tnnitrnrtiun Prrind Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: .......... ........ ......•. ..... ........ .... .... Location-Address t No ...... . Vcaner Address Wa� '� ................................... .................................................................---- Installe Address d Type of Building Size Lot.- feet feet U Dwelling—No. of Bedrooms_..._..: ___ .__..Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) Cafeteria ( ) Q' Other fixtures .------•---•--• --------------• - W Design, Flow............................................gallons per person per day. Total daily flow............................................gallons. Ix Septic Tank—Liquid capacity G 0.gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No____4____________ Diameter......_.._.......... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) `-' Percolation Test Results Performed by... ._f.�- L __ !+ '......................... Date... '�°"'f Test Pit No. 1. .....Minutesper inch Depth of Test Pit . ` ._�.. Depth to ground water _....��.....__. (z, Test Pit No. 2__ ...minutes per inch Depth of Test Pit...f4 ...... Depth to ground water....................... O w• - ---- --•-- ------------------------- ` . Description of Soil.. ____.z � / _._!✓�` �`_ d �24 .. .. v - - Agreement: '�'%A5V` A'IA�41 a a 14-rl' . The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of IT f,,. y g g p y S of the State Sanitary Code— The undersigned further reel not to lace the system in operation until a Certificate of Compliance has been issued. y the board of health. - Signed....... ....... .......................................... :�-, -•/ h��— Pate/ r Application Approved By..... `� .----•--••----•-•- " Date Application Disapproved for the following reasons----------------•-------•----•--•----•-------------------------...------------------------ ...................... ....................•---•----•-•-•---••-•-••-•-•---••-•••-----....-------•...-•-••-------------............ ---------------------------------------------------------------------------- Date PermitNo................. ......... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............OF..... raft/ ....................................... Turdifirab of Tomplittnrr THIS IS TO CERTIFY, That the In ��iv-dual Sewage D' posal 'System constructed ( or Repaired ( ) '., ' .. Installer has been installed in accordance with the provisions of TITL:: j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No..__ ...5 . .............. da.ted_..---------.................................... THE ISSUA CE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® A GUARANTEE THAT THE SYSTEM WIL1,41FOCTION SATISFACTORY. DATE......f/ /- ..........•.........::...•----...--•--_-_.... Inspector............... -•--------•••.....------------•---..._•---•--•---........-----••-- THE COMMONWEALTH OF MASSACHUSETTS }} BOARD OF HEALTH t`..E fA- '?:�:.........0F.---...A%4+ '..................................... No ��__�...... FEE.._ .: Diiprrsat Nor& Qlondkurtion pamit Permission i ereby granted............................. :ter. - �= to Constru or RqaZir,( ) an Indio' ual Sewage Disposal , 'AM atNo. 1 ..... .- -.d............ •-- Street - •-------------•--- ...../................................. Street as shown on the application for Disposal Works Construction_ ermit, No .•....... .......fib ed......................................... � . ..................................... <-' ja of Health DATE................................................................................ FORM 1255 HOBBS & WARREN, INC., PUBLISHERS No......LQ2:..�f.-Y F=3.! ............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Appliratinn for Dispnsttl Works Tonstrnetiun runtit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: /J,, ......... .ram......... f.1.`r.'N..rttl /.e !.._. 13L ..�� ..•••..........................................•............ / .......... .... - ...._.... Location-Address 2 �+�o-r Lot No ....... .C.7..c.__.9. 5'4. Sr:6..�c!� . ..... ....................... 3S_1...��xi...•'t•{-•....... L.r.U�S.�.t���..f:.lL Owner Address a .. ....... .................. ..................... ................................... .................................................. Installer Address Type,of Building Size Lot...� �.D.. �r..Sq. feet ,..� Dwelling—No. of Bedrooms......... -----------------------------Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building ............. No. of ersons............................ Showers p.t YP g ............... P ( ) — Cafeteria ( ) a Other fixtures ..............•----------------- . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid'capacit �J..gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No....sP........... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) / Percolation Test Results Performed by.... �Gsi l�i ,�>r _. . .__... .. Date....�- �.1 ✓_._...._.. $� �........r/ ._._. r ,aj Test Pit No. 1.. `...minutes per inch Depth of Test Pit..../_ �.�.. Depth to ground water........................ Li, Test Pit No. 2.._-',' ,QLminutes per inch Depth of Test Pit../.¢.,f.... Depth to ground water..... -..... P4 ._... ---- --- ... ....... ............................................. ... ... ..... ----- 0 Description of G4 i,Soil.-- -•# -- '�..-_:.,!u ..--•--�'....................................................1�� �-------- 'fa......�'�. vp....................•--........... . ...- Me_.P ...................,tea....--1��".�f' . �✓� 1\r + c =T 3 d.:-..lv.��...AW.. ............ ......................................................................................................_............�`!�.`..a.... .............. Agreement: 3U'— /,�V f�N The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iI'A U 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ' sued by he board of health. Y per' \ Signed.._..... A'�-....... ... 2Z Date Application Approved BY -- � ...... ,� ........ ate Application Disapproved for the following reasons:.............................................................................................................. ................................•----.........---•-•------........................_..._---•--•----.................----------...-------------•---••----•----•---.......--- •----......_.---... Date Permit NTr .................... No. F.Ha..................... THE COMMONWEALTH OF MASSACHUSETTS BOARD ® HEALTH ...... .... ...................... (' .� liration for Did wi 1 lark, Ton.5trurtiun ramit Application is hereby made for a Permit to Construct { or Repair ( ) an Individual Sewage Disposal System at: Add iL re ..._... ._!! ...................... �..-�......................................................... -...........7I Owner Address a ........................... ..........:. ..•• ................... •.....-•••----------.._....---•- . Installer Address Type of Building �'" Size Lot....�.....: - k Sq. feet Dwelling—No. of Bedrooms..........CJ................................Expansion Attic ( ) Garbage render ( ) Other—T e of Building ............ No. of persons............................ Showers — C%teria Other fixtures ............................... ..Design Flow............................................gallons per person per day. Total daily flow............................................ x Disposal TrenchLi undo ca acit �w dthns Length Total Length idth--------------•Total leaching area._-De Depth -:_....... W Septicq P Y--•--•----g a P sq. ft. > Seepage Pit No......e ......... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing t nk0-4 ( ) a Percolation Test Results Performed by.............. ..r-l..._.....:_.._.. .. ._ � Date... .. .:s:�-•_... a Test Pit No. 1... '..minutes per inch Depth of Test Pit......f. �} Depth to ground water........................ Test Pit No. 2--. _..::_..minutes per inch Depth of Test Pit...!r 3.r_;!-_... Depth to ground water........................ cxwi k.:_:. ,. ,► Si1c T � -----------------,--+-'--•--..... Q � 'f r '��. 'escrptonooXS . .6 - .. � • • -----•----•--•••----- ---------------------- { C .51 / _--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of`: TI: . 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been1nu d day t e board of health. . "t Signed � �r+;,�`_ eApplication Approved By. : .l'r_ .. /*t ... -------••----------------------•-----------•------ -----------•--....- -••---•---•-•-- Applieation Disapproved for tke followang reasons:.................. e Date PermitNo...........................................--............ Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS ..• "� BOARD OF HEALTH f.. .........OF...... .� ................................ Trrfifiratr at-Tamptiatirr THIS IS TO CERTIFY, That the Indivi ual Se age Disposal System constructed ( or Repaired ( ) .... .....-----•---•-••-••-.....--•-------•-------. Ins at------ ....... .._ .. 1�� ------- has been installed in accordance with the provisions ofI 5 of The State Sani ar Code as described in the P , application for Disposal Works Construction Permit No...............",eft.. ............... dated----------...................................... THE ISSUAN E OF THIS CERTIFICATE SH,►LL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL�/_/ ` TIO SATISFACTORvDATE �/ - - ---/--------. Inspector....._.... = :: THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH " r Not�' '"`,....;�.OF...... -:r. ....... .......-... L.......... FEE S f. ......... *........... I� / ! ......... Permission is hereby g � ranted.------...: -u ---------------------------------------------------- --------- ............. .--------- to Constru t r Re a' ).an Indiv'd 1 Sew age Disposal teen t r Street as shown on the application for Disposal Works Construction Permit No ....... ated.......................................... Je -' --------------------------------- 4ollyd�of Health DATE................................................ ... ..... ::P;,ORM 1255 HOBBS & WARREN, INC.. PUBLISHERS \ a j i LOCATION SEWAGE PERMIT NO. VILLAGE INSTA LLER'iiS NAME i ADDRESS BUILDER 0'IR OWNER —L�£L sH i DATE PERMIT ISSUED i DATE COMPILIANCE ISSUED_ i i I i i I c�4,04 L,21 N lh' i -33 / v` r.jl 04 N