Loading...
HomeMy WebLinkAbout0171 HOLLINGSWORTH ROAD - Health 128 HOLLINGSWORTH ROAD, COTUIT LA= 140 041 a I o Commonwealth of Massachusetts NO- 09/ r` �9 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments v 128 Hollingsworth Rd Property Address Owner Collin /Abiah Karthauser information is Owner's Name/ required for osterville y Ma 02655 4-22-2020 every page. Cityfrown State Zip Code Date of Inspection r 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 A. Inspector Information U forms on the computer, use Douglas A Brown only the tab key Name of Inspector to move your D.A.Brown Inc cursor-do not Company Name use the return key. P.o Box 145 Company Address r� Centerville Ma 02632 City/Town State Zip Code 508-420-4534 514297 Telephone Number License Number 13. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 4-22-2020 Inspector' 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts �v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments L; u 128 Hollingsworth Rd Property Address Collin/Abiah Karthauser inform Owneration is Owner's Name required for Osterville Ma 02655 4-22-2020 every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: At time of inspection this system met all minimum passing requirements. This report can not predict the future performance under the same or increased usage. 2) 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 'FIND (Explain below): t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts l�-p Title 5 Official Inspection Form 11. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^ � 128 Hollingsworth Rd ' Property Address Owner Collin/Abiah Karthauser information is Owner's Name required for Osterville Ma 02655 4-22-2020 every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) II 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3) 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. a. 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: t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts ry Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for VoluntaryAssessme nts 128 Hollingsworth Rd Property Address owner Collin/Abiah Karthauser information is Owner's Name required for Osterville Ma 02655 4-22-2020 every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: 4) 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 t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 r Commonwealth of Massachusetts rm i�A Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 128 Hollingsworth Rd Property Address owner Collin /Abiah Karthauser information is Owner's Name required for Osterville Ma 02655 4-22-2020 every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 'h day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 Commonwealth of Massachusetts �m I Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 128 Hollingsworth Rd Property Address owner Collin/Abiah Karthauser , information is Owner's Name required for Osterville Ma 02655 4-22-2020 every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes" to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: 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 backup? ® ❑ 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)) t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts I�-R Title 5 Official Inspection Form III Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4� 128 Hollingsworth Rd Property Address owner Collin /Abiah Karthauser information is Owner's Name required for Osterville Ma 02655 4-22-2020 every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN'flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 . Description: A main cesspool and a overflow cesspool were located and opened in the front yard.Pumping was not required as they were both empty. the first cesspool was 5.5 ft effective depth and the second one was 6 ft effective depth. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ❑ No If yes, discharges to: 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 d see below Detail: 2018--131.5 gpd 2019--213.6 gpd Sump pump? ❑ Yes ❑ No Last date of occupancy: seasonal Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts �. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 128 Hollingsworth Rd Property Address owner Collin/Abiah Karthauser information is Owner's Name required for Osterville Ma 02655 4-22-2020 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: 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 below): 3. Pumping Records: Source of information: Owner stated pumping for maintenance last fall. Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts I'F Title 5 Official Inspection Form 11. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 128 Hollingsworth Rd Property Address owner Collin /Abiah Karthauser information is Owner's Name required for Osterville Ma 02655 4-22-2020 every page. Citylfown State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known) and source of information: Appear to be original Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 4 feet Material of construction: ® cast iron ❑ 40 PVC clay pipe into cesspool and cast iron ® other(explain): out of foundation Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): appeared to be ok could not see any joints but clay pipe was viewable in main cesspool f5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts �v Title Official t e 5 0 cal Inspection Form I j' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 128 Hollingsworth Rd Property Address owner Collin/Abiah Karthauser information is Owner's Name required for Osterville Ma 02655 4-22-2020 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. 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: 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth &Massachusetts �n l Title 5 Official Inspection Form I° Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u � 128 Hollingsworth Rd Property Address Owner Collin /Abiah Karthauser information is Owner's Name required for Osterville Ma 02655 4-22-2020 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. 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 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 128 Hollingsworth Rd Property Address owner Collin/Abiah Karthauser information is Owner's Name required for Osterville Ma 02655 4-22-2020 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above,outlet invert N.A. Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 128 Hollingsworth Rd Property Address Owner Collin /Abiah Karthauser information is Owner's Name required for Osterville Ma 02655 4-22-2020 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. 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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: s Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: overflow cesspool number: main and ® p u ber: overflow In line ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 41� Subsurface Sewage Disposal System Form Not for Voluntary Assessments 128 Hollingsworth Rd Property Address Owner Collin /Abiah Karthauser information is Owner's Name required for Osterville Ma 02655 4-22-2020 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 2 in line Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction concrete block Indication of groundwater inflow ❑ Yes ® No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Both cesspools were opened and were dry at time of inspection. The main cesspool had clay pipe entering from the house and a pvc pipe and tee exiting towards overflow. the overflow pool was also dry with no signs of overflow or heavy staining at all. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts � 41' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 128 Hollingsworth Rd v Property Address Owner Collin /Abiah Karthauser information is Owner's Name required for Osterville Ma 02655 4-22-2020 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 f Commonwealth of Massachusetts �. l/,p Title 5 Official Inspection Form III I; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 128 Hollingsworth Rd Property Address owner Collin/Abiah Karthauser information is Owner's Name required for Osterville Ma 02655 4-22-2020 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form r II° Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4' 128 Hollingsworth Rd Property Address Owner Collin /Abiah Karthauser information is Owner's Name required for Osterville Ma 02655 4-22-2020 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: greater than 5feet 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: Septic install we did in that same general area no G.W. was encountered Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 cf 18 I - Commonwealth of Massachusetts rn I9 Title 5 Official Inspection Form III� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 128 Hollingsworth Rd Property Address Owner Collin /Abiah Karthauser information is Owner's Name required for Osterville Ma 02655 4-22-2020 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 18 of 18 6 r Assessing As-Built Cards Page 1 of 2 TOWN OF BARNSTABLE LOCATION _�oZ� F70��i�rf�,vOr �c SEWAGE 4 VILLAGE 0STafvJLt ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY CQ.S!RjZ LEACHING FACILITY.(type)�trS_QmI (size) NO.OF BEDROOMS �yy OWNER PERMIT DATE: COMPLIANCE DATE: 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 'tit Spu,'ren Z'. For �01 a 1 a 1 yy 1-7 a9 3 https://town.barnstable.ma.us/Departments/Assessing/Property_Values/HMdisplay.asp?ma... 4/22/2020 Assessing As-Built Cards Page 2 of 2; https://town.bamstable.ma.us/Departments/Assessing/Property_Values/HMdisplay.asp?ma... 4/22/2020 TOWN OF BARNSTABLE LOCATION _1 l�n ��. ✓ w z1 14 KL�SEWAGE # VILLAGE 4n � ( ASSESSOR'S MAP & LOT O INSTALLER'S NAME&PHONE NO. l<o b n-< a 41 ^ ,5-- F 7 7 Z SEPTIC TANK CAPACITY _ 6 6 _ LEACHING FACILITY: (type) 9 (size)NO.OF BEDROOMS y BUILDER OR OWNER LL CIA /� 5 PERMITDATE: 2 COMPLIANCE DATE:1 Separation Distance Between the: i Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) _ Feet Edge of Wetland and Leaching Facility(If any weftlands exist within 300 feet of leaching facility) Feet Furnished by SJ I TOWN OF BARRNSTABLE L"OCATION I�� 1q0 f(l�('1 GvOr Pei SEWAGE# VILLAGE tQSTtfy,16, ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY 0--SSRQ r LEACHING FACILITY:(type) CpI (size) NO.OF BEDROOMS . OWNER PERMIT DATE: COMPLIANCE DATE: 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 1 FURNISHED BY wit S T Fbr� /�. 0 A 6 Y_ . F� ,. a i Q yy i� �`� 3 gill TOWN OF BARNSTABLE LO&.nON SEWAGE # VILLAGE GSEL"I VIA- ASSESSOR'S MAP &LOT 4`(d t0q INSTALLER'S NAME&PHONE NO. LEACHING FACILITY: (type) (size) (0 NO.OF BEDROOMS BUILDER OR OWNER C' ra(u C:`,`C�►Pcv�] -P F' 'ATE: 1 14 -COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 2-0 1 Feet Private Water Supply Welland Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) t--)I V Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) N t Feet Furnished by fi>CP,?�l ell, Q� s (�Z- at5 i 8Z� 3Z1 LJ' Z E e, .tom TOWN OF BARNSTABLE Lr 'k. ION I SEWAGE # Q�:ATa� t�e:�,�,��a ��c� VILLAGES O (. ASSESSOR'S MAP & LOT - 1 INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER Q DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes , No �'• Cam../.a � i �"�...r�r '"1 I ��51� i '� I ��PT�G � t S' , eat. ^1c�.L l�vG'W c�2'� �� COMMONWEALTH OF MASSACHUSETTS i EXECUTIVE OFFICE'OF-ENVIRONMENTAL AFFAIRS DEPARTMENT`OF ENVIRONMENTAL PROTECTION TITLE-5' , OFFICIAL.INSPECTION FORM. .NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property'Address: 128 Hollingsworth Road l3 Osterville. MA, 02655 Owner's Name: ',. Ray Difflev Owner's Address: Date of"Inspection:`. December 22, 2007 Name of Inspector: (Please Print)James'M. Ford Company Name: James M Ford Mailing Address: P.O.Box 49 Osterville:MA_02655-0049 Telephone Number: (508).8624400 CERTIFICATION STATEMENT p r. I certify that I have personally inspected the sewage disposal system at this address and that the information reportedt below is true,accurate and complete as of the time of the,inspection. The inspection ias perforn ed based Qn my . training and experience in the.proper-function and maintenance of on site sewage.disposal systen%s I am a DEP approved'.system inspector pursuant to.Section 15.340 of4Title 5(310 CMR 15 000). The system:` + Passes c_n , Conditionally Passes Needs Further Evaluation by the Local Approving Aut f6rity F is ; Ins ,. . pectoris'Signature: Date: -: .Deceniber 3l'2007 The system inspector shall su it a`copy of this inspection report to the Approving-Authority.(Board-of Health or DEP)within 30 days:of completing this inspection jfJh. e system is a-shared system or has a design flow of 10,000 m gpd or greater,the inspector and the syste owner shall:submit the report toahe appropriate.regional office of the DEP. The original should be.sent to the.system owner and copies sent to the buyer,if applicable,and theapproving authority. 4, Y . Notes and•Comments. ****This report only,describes conditions atthe.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 . t conditions of use. Title 5 Inspection Form 6/15/2000 '; page 1. ` Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 128 Hollingsworth Road .Osterville, MA Owner: Ray DJAey Date of Inspection:; Decensber 31: 2007 Inspection Summary: Check A;B,C,D or E/ALWAYS complete all of Section D A. System.Pames; ✓ I have not found any information which indicates that any of the failure:criteria described in 11,0 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 bythe Board of health;will pass..:- Answer yes,no or not determined(Y,N,ND)in the for the following statements.'If"not determined",please explain. The septic tank"is metal and over 20 years.old*,or the septic tank(whether metal or riot)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,riot leaking-and-if a.Certificate of.Compliance indicating that the tank is less than 20 years old is available: ND explain: Observation.of sewage backup:or break out or high static.water level in the distribution box due to broken or obstructed pipe(s):or due to a broken,settled,or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction-is removed distribution box is leveled or replaced ND explain; The system required pumping more than 4.times a year due to broken or obstructed pipe(s).'The system will pass inspection if(with.approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of I OFFICIAL INSPECTION FORM;...NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART A CERTIFICATION (continued) Property Address: 128 Hollingsworth Road Osterville. MA _ Owner: Rau Difhev Date of Inspection; Decembee 31. 2007 C. Further.Evaluation,is Required by the Board of Health: Conditions exist whichrequirei further evaluation by the Board of Health.in order to detennine if the system is failing to protect public health,safety or the environment. 1. System will pass unless B.oard.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'feetof a:bordering vegetated wetland.or a salt marsh 2. System will fail unless the Board of Health.(and Public Water Supplier,'if any)determines that the system is functioning in a manner that protects:the-public health,safety and environment: The system.has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet.of.a surface water supply or tributary to a surface water supply. _ The system has a septic tank and.SAS and the SAS is within a Zone 1 of a public water'supply. The system has a septic.tank and SAS and the SAS is within 50 feet of a private water supply well. _ -:The system.has.a septidtank and SAS and the SAS is.less than 100 feet but 50 feet or more from a private water:supply*Well**...Method used to;detennine distance **This system passes if the well water analysis,performed at a DEP.certified laboratory, for colifonn bacteria and volatile organic compounds indicates that the'well is free from pollution from that facility and . the presence of ammonia nitrogen and nitrate nitrogen_is equal to or less than 5 ppm,provided that no other failure criteria.are triggered. A copy of the analysis must be attached to this form. . 3.' Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FO RM PART A CERTIFICATION (continued) Property Address: 128 Hollingsworth Road Osterville. MA Owner: Ray Difney Date of Inspection: Decenmber.31, 2007 D. System,Failure Criteria applicable to all systems: You must indicate either"yes"or."no to each of the-following f6r 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 levetin 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 ✓ 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 within1100 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 cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed At a DEP certified laboratory,for coliform.bacteria:and volatile organic compounds indicates that the well.is'free from pollution from that facility.and the presence of ammonia nitrogen and nitrate nitrogen is equal.to or less.than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to.this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15:303,therefore the system fails. The system owner should contact the.Board-of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000,gpd to 15,000 gPd• You must indicate either"yes"or`.`no to each of the,following`. (The following criteria apply to large'systems in addition to the criteria above) Yes No the system is within'400 feet of a surface drinking water.supply. _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in'a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes.."to any question.in Section E the system js considered a significant threat,:or answered "yes'.in Section D above theaarge 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 31.0 CMR `15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS . SUBSURFACE.'SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST ' Property Address: 128 Hollingsworth Road Osterville, MA Owner: Ray Difflev Date of Inspection: December 31, 2007 ` Check if the following have been-done: You must.indicate"Yes"or"no as to each of the following- Yes No t... 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 — — P 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 a — — ( Y s N/A) Was the facility or dwelling.inspected for signs of sewage back up?. _✓ Was the site inspected for-signs of break out 7 _ 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`ofsludge and depth of scum?. ✓ — Was the facility owner(and occupants,,ifdifferent from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes No _ Existing information, For example,a plan,at the Board of Health., , Determined in the field(if any of the failure cxiteria related to.Part Cis at issue approximation of distance is unacceptable).[310 CMR 15:302(3)(b)]. ' 3 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION-FORM PART C SYSTEM.INFORMATION Property.Address: 128 Hollingsworth Road Osterville, MA Owner: Ray"Difflev Date of Inspection: December 31, 2007 FLOW .CONDITIONS RESIDENTIAL Number of bedrooms(design): n/a Number of bedrooms(actual): 3 DESIGN flow.based on 310 CMR-15.203 (for example:.1.10 gpd x#of bedrooms);. 330 Number of current residents: ::0 Does residence have a garbage grinder(yes or no): n1a Is laundry on a separate sewage system(yes or no): n1a [if yes separate inspection required] Laundry system inspected(yes or no):.' No < Seasonal use(yes or no): No Water meter readings,if available(last2 years usage(gpd)): Unavailable Sump Pump(yes or:no): No Last date of occupancy Unknown f. COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): epd Basis of design flow-(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) r, Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,-if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping-Records ' Source of information:. Unavailable Was system pumped as part of the.inspection(yes or no): No If yes,;volume pumped: ' gallons.-=How was quantity pumped determined? . Reason for pumping:- TYPE OF SYSTEM 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.copyof the current operation and maintenance contract(to be obtained from systein 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:. Date of installation unknown . Were sewageodors detected when arriving at,the-site(yes or no): No r Page 7 of 11 , OFFICIAL'INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART SYSTEM INFORMATION.(continued) Property Address: ' 128 Hollingsworth Road , -Osterville,MA Owner: Ray Difley Date of Inspection:. December 31,2007 r: BUILDING'SEWER(locate on site plan),. Depth below grade: Materials of construction: cast iron 40 PVC other(explain) Distance from private water supply well or suction line: Conmients(on condition of joints,venting,evidence of leakage,`etc); ' s - SEPTIC TANK: ✓ (locate on site plan)- (Cesspool acting as a septic tank) - Depth.below grade: Cover to grade Material of construction: concrete:. metal _fiberglass _polyethylene ✓ other(explain) cesspool block If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no) (attach a copy of certificate) Dimensions: 5'W x 4'T x 8'6"bottom to ,rade ' Sludge depth: -- 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:: Measuring stick . Comments(on pumping recommendations,inlet and outlet-.tee or baffle condition,structural integrity,liquid levels as related to.outlet invert,evidence of leakage,etc.): e The Cesspool was dry:An outlet tee was present. GREASE TRAP: None.(locate;on site plan). Depth below grade;, Material of construction: _concrete metal .` fiberglass h_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: 'Continents(on pumping recommendations;inlet and outlet tee or baffle condition,structural integrity,liquid levels,.' as related to outlet invert,`evidence of leakage,etc.): < Page 8 of 11 . OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY"ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . SYSTEM INFORMATION(continued) Property Address: 128 Ho1 11 lhn6 orth Road r Osterville. MA Owner: Ray Diffley Date of Inspection: December.31 2007 TIGHT or HOLDING TANK: 'None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete_metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarn.level: Alarm in working order(yes or.no): Pate.of.last pumping: Comments(condition of alarm and float.switches,etc:): " DISTRIBUTION, BOX: None (if present must be opened)(locate on site plan) Depth of liquid.level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids"carryover,any evidence of leakage into or out.of box, etc): PUMP CHAMBER: None (locate on site plan) Pumps in working order_(yes or no): Alarms in,working order(yes or no) Con nients(note condition of pump..chamber,condition of pumps and appurtenances,etc.): r . . . 8 Page 9 of 11 j OFFICIAL INSPECTION.FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION:FORM PART C .SYSTEM INFORMATION(continued) Property Address: 128 Hollingsworth Road Osterville MA r Owner: RavDiffley. Date of Inspection: December:31 200.7 SOIL ABSORPTION SYSTEM(SAS): ✓ '`,(locate on site plan,excavation not required), If SAS not located explain why: Type leaching pits,*number: leaching chambers,number. x eaching galleries"number leaching renches,-number,length: leaching fields;number;dimensions: ✓ overflow`cesspool,number / Innovative%alternative system"; Type/name of technology: Cormnents(note condition of soil;signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,' etc.): The overflow was.dry There did not appear to be any signs offailure The bottom to grade was 9'6" The cover was 3"below CESSPOOLS None'(cesspool must be pumped as part of inspection)(locate on site plan) Number-and configuration; y Depth-top of liquid to inlet invert:r 9. Depth of solids layer:. Depth of scumaayer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or°no): Coirunents,(note condition of soil;signs:of hydraulic failure,.level of ponding,condition,of vegetation;etc.): i, PRIVY. None (locate on site plan)T .: Materials of construction: Dimensions: .,Depth of solids: - Conunents(note conditionOf soil;signs of.hydraulic failure,level of ponding,condition of vegetation,etc.): m 9 Page 10 of 11- >` - _.. •- ^ OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYS.TEM.INFORMATION(continued) Property Address. 128 Holliusworth Road Osterville, MA Owner: Ray Dif ey Date.of Inspection: Dedember`31. 2007 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 10.0 feet. Locate where public water supply enters the building. ILI Fr - { a i - Q �-q 3 `_ l0 . Page l l of 11 OFFICIAL INSPECTION FORM`-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION:FORM PART C SYSTEM,INFORMATION.(continued) Property Address 128 Hollin-esworth Road- Osterville, MA Owner: Ray Dif1ev Date of Inspection: December 31 -2007 SITE EXAM Slope R Surface water Check cellar A , Shallow wells Estimated depth to ground water, 30+1- feet Please indicate(check)all methods used to determine the'high'ground water elevation: Obtained from system'design plans on record-.If checked;date of design planreviewed: Observed site(abutting property/observation hole within 150.feet.of SAS) ✓ Checked with local Board of Health-explain: tono&avhic and water contoui s maps } Checked with local excavators,installers-(attach documentation) . Accessed USGS database=explain: You must describe how you established the high ground water elevation:- Using Barnstable tonoQranhie and water contours inans the maps were showing opPoxiinately 30'+7 round water at this site t. f This report has been prepared only for the septic system and components described her etn. .This septic systeni.has been inspected and passed as of the date of inspection.This report is not a warranty or guarantee.that the system will firnction properly.i the future:,There have been no warranties or guarantees, either expr`essed,.wr tten or.implied, relating to the septic system theinspection,this report and/or anycoinponents of the septic system which have not; been located and inspected: 11 Town of Barnstable �p I Tpk Regulatory Services aAxrsrns Thomas F. Geiler,Director v� iMb `0� AIFo �A Public Health Division 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., C0%1%10N«`E.ALTH OF MASSACHUSETTS EaECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF EN-VIRONNIE\TAL PROT ' 110 ONE WINTER STREET. BOSTON. MA 02106 JU L 1998 w WILLIA"i':F.WELD �F .�3EiTR U Gov ernc . - ! c'a ARGEO PAL1 CELLL'CCl DA Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM mission VAO PART A - 9 CERTIFICATION (1T-' . O t Property Address; .1 1�olkI#j.S cA (j'SVZCv,,l1-4?— Address of Owner: Date of Inspection: 6 (+� / :Of different) r. - Name of Inspector. 1 am a DEP a,Proved system inspector pursuant to Section 15.340 of Title S (310 CMR 15.000) Company Name:�}/7. c��r'e t�n r+ re .� we P r.'�•�� Q 26 S Mailing Address: 2 e3 /3ax e-3;'�j H 4Ke4e L H.-I-© aZ-4-C/ Telephone Number: r5-et,-Z !6 12-- 4c ZO CERTIFICATION STATEMENT 1 cenif1 that I have pe!sonall%- inspected the sewage disposal systern at this address and tha: the information reported below is true. accurate and complete as o:the time of inspec-oon. The inspect.on was performed based on my training and experience in the proper function and maintenance o;on-sae sewage disposa; systems. The Stern: Passes �I _ Concioonaii% Passes Need; Further Evaluation 5v the Local Approving Autnorim F Inspector's Signature: Date: (OhAb* T;ie S%•ste r Ins.^.eco, sha!• subml: a cop,.• of this inspecoon reoort to the Approving Authority within them (30) days of completing this inspectoon. lr the s\•stem is a shared s\•stern o• ha; a design flow of 10,000 god or greater, the inspector and the system owner shall submit the repo tic the appropriate regional office of the Deparment of Environmenta' Protection. The crig:na! should be seat to the sysiem owner and copes !--it,to the buyer, if applicable. and the approving authority. INSPECTIOti SUMMARY: Check A, B, C, Or D: Al 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 indicAte�d below. ' COMMENTS: Teew\ m l S TINT BI SYSTEM CONDITIONALLY PASSES: One or more system components as described in the 'Conditional Pass' section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N. or NDi. 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 (attachedi 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 tank as approved by the Board of Health. (revised 04/25!97) Page 1 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM • PART A CERTIFICATION (continued) .�f r - - • ` ��:_.. ��:( •1 / - -.yam �,iy s L Y...1YT�._r s �.E'io erty Address: _ _ •:L s _ �� �'Y .. - . }a '�- ��. Owner , � : a." ..r.;, .Tt'` ... s .� -r -.;LT;".�" = "? .. Date of�spectlon: �3 81 SYSTEM CONDITION LLY ONDIT ONALLY PASSES tcont,n,,,!�d SK�oSewagetbackup or breakout or high static water level observed in the distributio ox is due to broken or obstructed pipeiwor due to a broken• settled or uneven distribu:ion.box. The system will ass inspection if(with approval of the Boa of Health). Describe observations: /� broken pipe(s) are replaced obstruction is removed - distribution box is levelled or replaced _ The system required pumping more than four times a year due to bro en or obstructed pipe's).,The system will pass inspection if twith approval of the Board of Health): broken pipets► are replaces obstruction is removed . • _ C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require furthe•evaluation by the Board of ealth in order to determine if the system is failing to protect the public health. safer•and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMI S THAT THE SYSTEM 15 NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAF AND THE ENVIRONMENT: Cesspool or prn1 is within 50 feet of a surface w ter Cesspool or pri�� is w ithin 50 fee: of a borderin vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALT (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM 15 FUNCTIONING IN A MANNER TH PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil abs rption system US) 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 sorption system and the SAS is within a Zone I of a public water supoty well. The system has a septic tank and soil bsorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soi absorption system and the SAS is less than. 100 fee: but 50 feet or more from a private water suppl} well, uniess a ell water analysis for coliform bacteria and volatile organic compounds indicates that B the well is free from pollution fro that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used t determine distance (approximation not valid). 3) _.OTHER r . r (:ilviseZ 04!25197) / Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: D) SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as deli ed in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to deter ine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or logged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface w ers due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an verloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available vo ume is less than 112 day flow. Required pumping more than 4 times in the last year NOT due t clogged or obstructed pipe(s). Number of times pumped_ Anv portion of the Soil Absorption System, cesspool or privy below the high groundwater elevation. Anv portion of a cesspool or privy is within 100 feet of a s rface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I o� public well. Am portion of a cesspool or privy is within 50 feet o a private water supply well. Any portion of a cesspool or privy is less than 100 eet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has n analyzed to be acceptable, attach copy of well water analysis for cohiorm bacteria, volatile organic compounds, a monia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the follow ng: The following criteria apply to large systems in addit n to the criteria above: The system serves a facility with a design flow of 0,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment be use one or more of the following conditions exist: Yes No the system is within 400 feet of a s ace drinking water supply the system is within 200 feet of a ibutary to a surface drinking water supply the system is located in a nitrog sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone it of a public water supply well) The owner or operator of any such system shall ring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Pleas consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 rt !1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes 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 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: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. — Existing information. Ex. Plan at B.O.H. — Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)) (revised 04/25/97) Pago 4 of 10 i , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR,.m PART C SYSTEM INFORMATION Properh Address: %Z� ��vl�tr• tiv Owner: Date of Inspection: �C� FLOW CONDITIONS RESIDENTIAL: Design flow 37 e.p.d./bedroom for S.A�S Number of bedrooms Q3 Number o-.current residents©2.:. Garbage g•, der (yes or nor Laundry co-•^ected to system (yes or no' Seasonal use Ives or no,. Water meter readings, if available (last two i2, year usage tgpdt: Sump Pump Ives or not Last date o'occupanc, COMMERCIAL'INDL'STRIAL: Type of establishmen: Design fio%% _gahons day Grease trap present rues or no' Industria! \taste Holding Tani; present -ves or no Non•sanitar\ Haste discnargec to the T!t,e 5 system ;ves or no_ %later meter readings if a%allabie Las:pate o; o c;:;,anc-\ OTHER: .De:cribe Last date of occ:oanc. GENERAL INFORMATION PUMPING RECORDS and source f informaiion System pumped as par, of inspection: (ves or no. kf7l� If ves, volume pumped ¢allons Reason for pumping TYPE OF SYSTEM Septic tank/distn uuon box/soil absorption system Single cesspool IGUL Tkdo Cs�1Qc�cy� Overflow cesspool Prn�• Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technologv etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site. (yes or not (seviaed 04/25/9*7) YsQ• 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: BUILDING SEWER: (Locate on site plant Depth below grade. Material of construction: _cast iron _40 PVC _other (explain` i Distance from private water supply well or suction Ij-< Diameter Comments: (condition of)oints, venting, evidence of leakage. etc.) SEPTIC TANK:_ (locate on site plan Depth below grade Material of construction: _concrete _meta _Fiberglass _Pol\,ethvlene /heriexplain` If tank is metal. Iis: age _ Is age confirmec b\ Ce­t;6ca:e of Compiiance (lies-No Dimensions Sludge depth Distance from top o: sludge to bortorn o' outie: tee o, ba^;e Scum thickness Distance from top o; scum to top of outlet tee or ba^+e Distance from bonom of scum to bo-o^n of outlet tee e, bane Now dimensions were determined i Comments trecommendation for pumping. condition of inlet and outlet tees o4affles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage. etc.; GREASE TRAP: (locate on site plan: Depth below grade. Material of construction: _concrete _metal Fibergl ss _Polyethylene _other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or b le. Distance from bottom of scum to bottom of outlet ee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of i! et and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.; (revised 04/25:97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propem Address: ON ner: Date of Inspection: TIGHT OR HOLDING TANK: Tank must be pumped prior to, or at time, of inspecaio (locate on site plan, Depth below grade.Material of construction _concrete _metal _Fiberglass _Polyethylene _other(ex4in) / Dimensions. ` Capacity gallons ? r Design flo" galions-da, % Alarm level A;arm in %%orking order_ Yes: _ No / Date of previous pumping j Comments (condition of inlet tee. condition o• a!a•rr. and float switches, etc.i / i DISTRIBUTION BOX:_ docaie on site pan t Depth of mould leve' aoo,e outle: rme" I Comments i mote if leve! and d!stribu:!or eoua' evidence of solids carryover, evidence of leakage into or out of box, etc.i PUMP CHAMBER: (locate on site plan_ Pumps in working order: (Yes or No, Alarms in working order (Yes or No Comments: (note condition of pump chamber, condrti n of pumps and appurtenances, etc.) A. (revised 04/25/97) / Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):19 (locate on site.plan, ifpossible, excaXi n not required, but may be approximated by non-intrusive methodsi If not determined to be present, explain. Type: leaching pits, number._ leaching chambers, number: leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimen4ionls ovei4low cesspool, number Alternative s%,stem Name of Technoiog\ Comments. tnotecondition of soil. signs or hydraulic failure, level of pondmg, con4tion f veg ation, etc.' (V t CESSPOOLS: (locate on site par. Number and conf,gura-,-or. Depth-top of liquid to inlet Inver, Depth of solids layer 1i Z" Depth of scum layer. Q. ,Dimensions of cesspool 9�, Materials of construction Ct�NG.VLts)CQ_ C Indication of groundwate• Qcc, _ inflow tcesspool must oe pumpeC as par, of inspections NC). — cSVl�.+�5� Comments: (note condition of soil, signs of hydraulic failure,�level of p nding, ndition veg tion, etc.) PRIVY:Vv ;locate on site plan) Materials of construction: Dimensions. !depth of solids: Comments: inote condition of soil, signs of hydraulic failure, level of pond'ng, condition of vegetation, etc.) Crevaeed 0�/25/97) Page rt of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM NFORMATION (continued; Propert. Address: o-+lwc72t Owner: Date of Impeclion:�Itt SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reierences landmarks or benchmarks locate all wells within 100• (Locate where public water supply comes into house) Q � J 3Z (rev aaad 04125197) Pago ! of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO% FORM PART C SYSTEM INFORMATION (continued) Propert+ Address- 2.TI, Owner: Date of lnspecuon:G I ll c� t 20 Depth to Groundwater _ Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained irom Design Plans on record Observation o� Site (Abutting property, observation hole, basement sump etc.) Determine it irom .local conditions Cneck %+ah Iota' Beard o• neaar Chec'� F:.%t:. Mam Cnect, pumping recorcc Chec►. Iota' exca�a;o•s ins;alle•t• seLS _ D o.� Describe in .cx o••- v.xci eo•., \o_ es:ac'.:Shec the CroundMate' Elevation (Must be compie:ec. Ut S, '=jko t Qci l c c'3 5U iwtt f'�&Vx\0 y C �Nv. r�q cn is t 14. A 6 C Z i (revcs.d :4.•:S •9- page 10 of 20