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HomeMy WebLinkAbout0117 PARKER ROAD - Health (2) 117 PARKER ROAD, OSTERVILLE A= 116029 a - - I TOWN OF BARNSTABLE LOCATION Q'�+ ` SEWAGE# f� VILLAGE Q n �1 ASSESSOR'S MAP&PARCEL \\La 026 INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 17� Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) /J A Feet Edge of Wetland and Lea ing Facility(If any wetlands exist within 300 feet of le(chi g facility) Feet FURNISHED BY i CP 3l � a 44 5'7 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 117 Parker Road Property Address Margaret Dwyer Owner Owner's Name information is required for every Osterville MA 02649 10/15/10 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 forms A. General Information on the computer, I use only the tab 1. Inspector: key to move your cursor-do not Carmen E Shay' use the return Name of Inspector key. Shay Environmental Services, Inc: U18 Company Name 185 Ashumet Road Company Address Bw� Mashpee MA 02649 -City/Town State Zip Code 508-539-7966 3080 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this ad s and tIr the information reported below is true, accurate and complete as of the time of thew]] ection. Se inaction was performed based on my training and experience in the proper function and❑.r. intenance of on1'gite sewage disposal systems. I am a DEP approved system inspector pursuant br ection .34 f Title 5 (310 CMR 15.000). The system: -v Cn ® Passes ElConditionally Passes ❑ Fail X= rn ❑ rNeeu ation bythe Local Approving Authority10/15/10 Inspture 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. V 117 Parker Road,Oslerville,MA(2)•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 117 Parker Road Property Address Margaret Dwyer Owner Owner's Name information is required for every Osterville MA 02649 10/15/10 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: Cesspool with Overflow Leach Pit present. 3' liquid in leach pit, 3.5' Stain line. No evidence of backup B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. . Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed 117 Parker Road,Osterville,MA(2)•03/08 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 117 Parker Road Property Address Margaret Dwyer Owner Owner's Name information is required for every Osterville MA 02649 10/15/10 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. 117 Parker Road,Osterville,MA(2)•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 117 Parker Road Property Address Margaret Dwyer Owner Owner's Name information is required for every Osterville MA 02649 10/15/10 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 ❑ ® 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 ® 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. 117 Parker Road,Oslerville,MA(2)•03/08 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 117 Parker Road Property Address Margaret Dwyer Owner Owner's Name information is required for every Osterville MA 02649 10/15/10 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. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ .0 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. 117 Parker Road,Osterville,MA.(2)•03/08 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 117 Parker Road Property Address Margaret Dwyer Owner Owner's Name information is required for every Osteryille MA 02649 10/15/10 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 ❑ N 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)] 117 Parker Road,Osterville,MA(2)•03/08 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 117 Parker Road Property Address Margaret Dwyer Owner Owner's Name information is required for every Osterville MA 02649 10/15/10 page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 5 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: Unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203); Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): i 117 Parker Road,Osterville,MA(2)•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15, I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 117 Parker Road Property Address Margaret Dwyer Owner Owner's Name information is required for every Osterville MA 02649 . 10/15/10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: None available 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): ,Approximate age of all components, date installed (if known) and source of information: 1970's Were sewage odors detected when arriving at the site? ❑ Yes ® No I 117 Parker Road,Osterville,MA(2)•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 117 Parker Road Property Address Margaret Dwyer Owner Owner's Name information is required for every Osterville MA 02649 10/15/10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 20 inches 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.): No evidence of leaks, plumbing properly vented Septic Tank (locate on site plan): Depth below grade: 1 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 l Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? 117 Parker Road,Oslerville,MA(2)•03108 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 117 Parker Road Property Address Margaret Dwyer Owner Owner's Name information is required for every Osterville MA 02649 10/15/10 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.): 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.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain). I 117 Parker Road,Oslerville,MA(2)•03/08 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 �M 117 Parker Road Property Address Margaret Dwyer Owner Owner's Name requnfo ir required is Osteryille MA 02649 10/15/10 required for 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 D-Box Present 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 117 Parker Road,Oslerville,MA(2)-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 117 Parker Road Property Address Margaret Dwyer Owner Owner's Name information is required for every Osterville MA 02649 10/15/10 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: 1-6'diam x 6' D ❑ 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.): Cesspool with Overflow Leach Pit present. 3' liquid in leach pit, 3.5' Stain line. No evidence of backup 117 Parker Road,Osterville,MA(2)•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 f - Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 117 Parker Road Property Address Margaret Dwyer Owner Owner's Name information is required for every Osterville MA 02649 10/15/10 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 1-ACTING AS SEPTIC TANK Depth —top of liquid to inlet invert Equal with outlet invert Depth of solids layer 5.5' Depth of scum layer 1/4" scum noted Dimensions of cesspool 6' x 6' diam 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.): No evidence of hydraulic failure. Cesspool acting as a septic tank. 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.)-. 117 Parker Road,Osterville,MA(2)-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 � T - Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 117 Parker Road -- - roperty Address Margaret Dwyer -------- Owner Owner's Name information is Osterville MA 02649 10/15/10 required for every -- State Zip Code Date of Inspection page. City/Town 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. -in%A,hnr. niihiir• uiatPr Sttnnly Pnters the building PARKER ROAD , SwinE Ties: Water;Line A- Cesspool—3 L' B- Cesspool—50' A—Leach Pit-44' , B—Leach Pit—59' Exist House A B Cesspool Acting As A Septic Tank O 0 0 Overflow 10 117 Parker Road,Osterville,MA(2)•03/08 Title 5 Official Inspecuon rorm.z�uosunace�ewaye v Pv—oy--- aa= Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a �^M 117 Parker Road Property Address Margaret Dwyer Owner Owner's Name information is required for every Osterville MA 02649 10/15/10 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: 14 + feet. 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: refer to Topo Maps and plans on file i 117 Parker Road,Osterville,MA(2)•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 COMMONWEALTH OF M"A"SSACHUSETTS z f EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION n TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION C-5- Property Address: #117 Parker Road. �F Osterville,MA rn Owner's Name: Margaret Dwyer Owner's Address: 40 Carver Road Wellesley Hills,MA 02181 y Date of Inspection: 11/30/06 cu c-n r Name of Inspector: (please print) Mr. Carmen E.Shay Company Name: Shav Environmental Services,Inc. Mailing Address: 34 Thatchers Lane East Falmouth,MA 02536 Telephone Number: (508)-548-0796 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: XX Passes -,NOFMgss9`�+" Conditionally Passes y� o Needs Further Evaluation by the Local Approving Authorit o� CARMEN tiN Fails E. 91 v SHAY Z� Inspector's Signature: Date: 11/30/06 AC, TlF\�`�Q �FS INSPE�' The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Healt DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments Cesspool Acting as a Septic Tank with an Overflow Leach Pit. Liquid Level in Leach Pit meets the required inspection criteria for Title V. No Liquid observed in pit. Stain line observed at 3'. 3 Effective Sidewall Available. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 t Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: #117 Parker Road Osterville,MA Owner: Margaret Dwyer Date of Inspection: 11/30/06 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: XX I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: T ., 2 t Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: #117 Parker Road Osterville,MA Owner: _ Margaret Dwyer Date of Inspection: 11/30/06 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 — P Y Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: o Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: #117 Parker Road Osterville,MA Owner: Margaret Dwyer Date of Inspection: 11/30/06 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _X_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 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• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well - If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. r -I 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: #117 Parker Road Osterville,MA Owner: Margaret Dwyer Date of Inspection: 11/30/06 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No XX _ Pumping information was provided by the owner,occupant, or Board of Health XX Were any of the system components pumped out in the previous two weeks? XX _ Has the system received normal flows in the previous two week period? XX Have large volumes of water been introduced to the system recently or as part of this inspection? XX _Were as built plans of the system obtained and examined?(1f they were not available note as N/A) XX _ Was the facility or dwelling inspected for signs of sewage back up? XX _ Was the site inspected for signs of break out? XX _ Were all system components,excluding the SAS, located on site'? XX _ 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? XX _ 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 XX _ Existing information. For example,a plan at the Board of Health. XX _ 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)] f Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: #117 Parker Road Osterville,MA Owner: Margaret Dwyer Date of Inspection: 11/30/06 FLOW CONDITIONS - RESIDENTIAL Number of bedrooms(design): 5 Number of bedrooms(actual):_5_ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 Number of current residents: 0 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no):_ Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no): No Last date of occupancy: Currently Unoccupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Unknown 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 XX 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 T Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: 1960's& 1970's-per Homeowners&BOH Records Were sewage odors detected when arriving at the site(yes or no): No I Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #117 Parker Road Osterville,MA ' Owner: Maruaret Dwyer Date of Inspection: 11/30/06 BUILDING SEWER(locate on site plan) Depth below grade: 20" Materials of construction: cast iron XX 40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: _(locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 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.): GREASE TRAP:_(locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): r .„ 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #117 Parker Road Osterville,MA Owner: Margaret Dwyer Date of Inspection: 11/30/06 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (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: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SS SSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #117 Parker Road Osterville,MA Owner: Margaret Dwyer Date of Inspection: 1.1/30/06 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type 1 leaching pits,number: 6' diam by 6' deep Overflow Leach Pit leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No evidence of hydraulic failure, ponding damp soil or stressed vegetation. Probed stone around SAS with a 6' probe with no evidence of hydraulic failure noted. Inspection inside Cesspool revealed no standing water. 3'stain line observed. CESSPOOLS: 1—ACTING AS SEPTIC TANK (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: 1_ Depth—top of liquid to inlet invert: No liquid—cesspool was dry from non occupancy., Depth of solids layer: 5.5 Depth of scum layer: No scum Dimensions of cesspool: 6' x 6' Materials of construction: Cement Block Indication of groundwater inflow(yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Stain lin indicated liquid level equal with outlet tee invert and overflows into overflow Properly_ PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): . Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #117 Parker Road Osterville,MA Owner: Margaret Dwyer Date of Inspection: 11/30/06 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. PARKER ROAD Swing Ties: Water',Line A- Cesspool—3 L' B- Cesspool—50' I A—Leach Pit-44' B—Leach Pit—59' Exist House A B Cesspool Acting As A Septic Tank O � Overflow T ,. . , 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #117 Parker Road Osterville,MA Owner: Margaret Dwyer Date of Inspection: 11/30/06 SITE EXAM Slope Surface water - '/4 to''/2 mile+/- Check cellar -Yes Shallow wells—None Estimated depth to ground water 15+/- feet Please indicate(check)all methods used to'determine the high ground water elevation: , Obtained from system design plans on record-If checked,date of design plan reviewed: XX 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) XX Accessed USGS database-explain: You must describe how you established the high ground water elevation: Inspector has performed perc tests in area. Per USGS MAP PLATE 2: Elev.of Ground=32 Feet Elev.Of Groundwater=5 Feet Elev.Of Bottom of Leach Pit 25 Feet i Therefore: 24—5 = 19 feet separation between Bottom of Leach Pit and Groundwater. Groundwater Adjustment using Index Well MIW-29 : 2.0 feet Adjusted Groundwater Separation=24' -7= 17 feet between bottom of Overflow and adL groundwater Grade=Elev. 32 feet Overflow Cesspool Bottom of Overflow=Elev.25 feet Adj. Groundwater=Elev. 7 r - C"L-4- 'M Commonweafth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection Willlam F.Weld Goverrwr _._Trudy.-.Coxe Argeo Paul Celluccl seaeuq u.C+orsmor David B.Struhs Commmmoner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORMt PART A _ � o CERTIFICATION o Property W m� Address- , / Address of Owner. ti Date of Inspeotion: —I / •. of different) S E P 1 9 Name of Inspector. C ar ko•• �� t`+ S_ Company Name,Address said Telephone Number. s IM3ii1?m CERTIFICATION STATEMENT I certify that I have personally ins the sews �° , ci_ �e Pe Y P�� sewage disposal system at this address and that the information reported: low�'=trueaocurate and complete as of the time Of inspection. The inspection was performed based on my training and experience in the proper-€isnt tmn amend maintenance of on-site sewage disposal systems. The system: Passes — Conditionally Passes — Needs Further Evaluation By the Local Approving Authority Fails q Inspector's Signature: n ,-S) `\--_ d� Date* St d1 9 1 b The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C,or D: A] SYS�'EM PASSES: - _� [have not S uud any 1Y SV u ;;. .' 3. '. .; i:.:system violates any of the failure criteria as tu.ra u in J"ou 4 Stih 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: i One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair, passes inspection. 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, 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 ponforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 . One VAnter Street a Boston,Massachusetts 02108 a FAX(617)556-1049 s Telephone(617)292-5500 ie}Printed on Recyded Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:t l r 1 '�t'�t'uLc r ��. � �(�i Akv. ef'-.6- Owner. i �\ tiy�ry `�^� �prneN sbeJ Date of Inspection: B] SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution bra is due to broken or obstructed pipe(a) or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(a)are replaced _ obstruction is removed distribution box is levelled or replaced I 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 Cl 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 PROTECT THE PUELIC.EEALTH 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 within 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 tank 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 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 leas than 5 ppm. 3) ,OTHER (revised 11/03/95) 2 ' W SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A n m CERTIFICATION(continued) Property Address: (� 1 ` mclr R� OS s 11 f, ary10.. Owner. v,+ k\"0vgVN '-J'Vt6QN$tni Date of Inspection: 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 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of tunes pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: 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 environment because one or more of the following conditions east: ^he system is within 400 feet of s surface drinking water supply the system is within 200 feet of a tributary to a surface drinlring water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone U of a public water supply well) x 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. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: b Wu(,V" RD ©SV--,%\`4 , Owner. of Inspections: Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. ZNone 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 r The facility or dwelling was inspected for signs of sewage back-up. ZThe system does not receive non-sanitary or industrial waste flow 4r 'The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. ZThe 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. V/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. ZThe facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: i P(,-CV c`r_ QD. VS�tcl-% k, Owner'. W 1�, egh��Soo Date of Inspection: FLOW CONDITIONS RESIDENTIAL• Design now: '-"!S —gallons Number of bedrooms: 3 Number of current residents:-2- Garbage grinder(yes or no):�1 Q Laundry connected to system(yea or no):*G Seasonal use(yes or no): Water meter readings,if a ble: Last date of occupancy: COMMERCIAL/INDUSTRIAU Type of establishment: Design flow:_gallons/day, Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: i q Lj—7 t'm Last date of occupancy: J ' OTHER:(Describe) Last date of oc upancy: GENERAL INFORMATION PUMPING RECORDS and source of information: i `q .k-m r e cc System pumped as part of inspection: (yes or no) 114 If yes,volume pumped ,6O b gallons Reason for pumping- TYPE OF SYSTEM �14trit Septic tank/distribution box/soil absorption system _-VOveral w cesspool Privy. : Shared system(yes or no) (if yes, attach previous inspection records, if any) Other(explain) APPROXIMATE AGE of all components, date installed(if known)and source of information: `pm 1950 Nb 1q Blt,'f Sewage odors detected when arriving at the site: (yes or no) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: � �, P0.rkero. oSTCc� i14. W.CI . Owner. WIOM,0.M 5- �Q1�erssca Date of Inspection: �qq� SEPTIC TANK:_ (locate on site plan) Depth below grade: Material of constriction:_concrete_metal_FRP_other(ezplain) Dimensions: Shidge depth: Distance from top of shidge 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: 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.) GREASE TRAP-j jj0, l'e (locate on site plan) Depth below grade: Material of construction:_concrete_metal_FRP_other(e:plain) 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: 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.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: �`� Q 0s v"-V �d. OS Q ; �; -MeA. DotInsmol\i Inspection: 3ke��nl�.1S�� sep� . ►� . �qa � TIGHT OR HOLDING TANK:_ (locate on site plan) Depth below grade: Material of construction:_ocncrete_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:_YQ N (locate on site plan) Depth of liquid level above outlet invert: - Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box,etc.) PUMP CHAMBER:- (locate on site plan) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFO` TION(continued) Property Ad I l`] PQCker OS}erV� Owner. aM %�e 'etJ$0 o Date of Inspection: SOIL ABSORPTION SYS •(SAS):' q 9 6 (locate on site plan, if poswble;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: leeching pits, number._ leaching chambers, number._ leaching galleries,number. leaching trenches, number,length: leaching fields, number,dimensions: overflow cesspool,number- Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation etc. CESSPOOLS: S 1s �s `1 �y�e W Cd S5 0x (locate on site plan) Number and configuration: t�c3 'rid Depth-top of liquid to inlet invert- Depth of solids layer. Ak\—, Depth of scum layer. W 1 cps , SP ��'I Z Dimensions of spool: C_Q `i Materials of construction: S_ l') Indication of groundwater. IVf2 S inflgw(cesspool met be j7umped as of' ion) Cr y it t oc o a D-Jy\ � c o S a Less V00 o� Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.) t4 C �•tC edY' II (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.) (revised 11/03/95) g SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Addreee: Owner.Date of Inspecpe ti s4r e—p\-\0- �6 on: SKETCH OF SEWAGE DISPOSAL SYSTEM; include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' O s � x � , D f DEPTH TO GROUNDWATER Depth to groundwater. t feet method of determination or a rvzimation 1000 rlti `L�c r �` c� •_., (revised 11/03/95) 9