HomeMy WebLinkAbout0162 STARBOARD LANE - Health 162 (2) Starboard Lane
Osterville p
t A = 166 106 M �"
DATE ;'_6/13/02 ----
PROPERTY ADORESS:,; 162 Starboard- Lane-
Osterville�Mass . __----
02655
On the above date,, I Inspected the septic system at the above a dre
This system consists of 'the following;
1 . 2-1000 gallon precast leaching pits . West side. ;o.f house 6 'X9 =.
2 . 6 'X8 ' block cesspools . -On-,the east ,side of .house .
The pits are in series . T0, 6 �Q
The cesspools are .in series .
Based on my. Inspection, I certify the following conditions:
3 . This is not a title five septic system. FAs�
4 . This is a sewage system. ( Prior 1978 ) ( ,No tanks
5 . The two pits are dry . Overflow pit has never been full . Stain
37" below the invert pipe.
6 . Cesspools are presently in working order .Overflow is dry .
1, The sewage system is in proper working order at the present time .
, 8. One thing in question is the property line on he west side of
the house . Presently one of the its are on an ov r e ne .
9 . Dispute is now taking place , pSIGNATURE :�
Name : i P Macomber r.
Company ; Joseph _P , Macomber & .Son , 'Inc
ress : Box 66
CencerJille , Me . '02632-0066
Phone : 508_775_ 3338___ —_
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER & SON, INC.
Tanks Cesspools Leachfleldi
Pumped & Installed
Town Sewer Connections
P O. Box 66 Centerville, MA 02632.0066 ~
775.3338 775.6412
M
COMMONWEALTH OF MASSACHU.SETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL'PROTECTION
v
r TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 162 Starboard Lane
Osterville .Mass .
Owner's Name: Windle Priem
Owner's Address: 174 Starboard Lane
Osterville .Mass . 02655
Date of Inspection:6/13/0 2
Name of Inspector:(please print),Joseph P .Macomber Jr . "
Company Name:J.P.Macomber & Son Inc .
Mailing Address: Box 66
C:PntPryJ11P ,MaG_q _ '
Telephone Number: sng-775—VA4
CERTIFICATION STATEMENT
I certify that 1 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:
asses
'�✓ Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: l Date: /5rdA
The system inspector shall s mit 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. .
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form • 6/15/2000 page 1
Page 2 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 162 Starboard Lane-
stervi e , ass .
Owner: Windle Priem
Date of Inspection: 6, 13 0 2
Inspection Summary:
Cbec)k A B C,D),or.E/ALWAYS complete all of Section D
A System Passes:
fi5 II have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or ut 310 C v'f f 15.304 Any failure criteria not evaluated are indicated below.
Comments:
One of the leaching pits on the west side of ',t:h.e' house
not on property . Survey stake is on pit , is should e
corrected . If not corrected . I am sure a civil court battle
will become reality .
B. S stem Conditionally Pas
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.
r
d12C,The se tic tank 's 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:
,IiU ,Observation of sewage backup or break out or high static water level in the(d-i-s;-ib-u—ti-o-n-b-o-xNdue 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:
N0 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 l l
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE_ DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Propert• Address: 162 Starboard Lane'
Osterville ,Mass .
OwnerWindle Priem
Date of laspectioa: 6/13/0 2
C.(�
�urither�Evalua�tionisRequired by the Board�ofHea�lt .
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 saface water'
Cesspool or privy is witbin 50 feet of a bordering vegetated wetland or a,salt marsh
2. Svstem will fail unless the Board of Health (and PublieVater Supplier, if any) determines that the
system is functioning in a manner that protects the public health, safety and'environmenti
PP 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.
XP The system has a septic tank and SAS and the SAS is within a Zone I of a public water supplj•.
L The system has,aseptic tank and SAS and the SAS is within 50 feet of a private 4water'supply well.
The system has a septic tank and SAS and the SAS is less than 190 feet but feet or more from a' -
private water supple well I,. Method used to determine distance - / -
'This system passes if the well water analysis, performed at a DEP cenified'laboratory; for col.iform
bacteria and volatile organic compounds indicates that the well is free from pollution from that Wility'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 anached.to this form.
3. Other:
6�D -This is a split system. Eastside has two 6 'X8'
block cesspools . There are two 1000 gallon precast
leaching pits in series on the west side of house .
3
Page a of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 162 Starboard Lane
stervi e , ass .
Owoer:Windle Priem
Date of Inspection: 6/ 13/02
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 ponclog 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 dismbun n box bove outlet invert due to an overloaded or clogged SAS or
cesspool ,s;,
Liquid depth in cesspoorisless than 6"below invert or available volume is less than'h day now
/Rcquired pumping more than 4 times in the last year NOT due to clogged or obstructed pipc(s). Number
of times pumped �.
_ Any ponion of the SAS, cesspool or privy is below high ground water elevation,
Any ponion of cesspool or privy is within 100 feet or a.surface water supplyor triibutary to a surface
water supply.
Any ponion of a cesspool or privy is within a Zone I of a public well.
_ �tny ponion of a cesspool or privy is within 50 feet of a private water supply well.
� An,v ponion of a cesspool or privy is less than 100 feet but greater than 50 fect.from a private-water
supply will with no acceptable water quality analysis. ITbis 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 oitrogen'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.1
Vid (YesTO) The system fails. 1 have determined that one or more of the above failure criteria exist as
described in 310 CMR- 15 303. therefore the system fails. The system owner should contact the Boare
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 now of 10,000 gpd to 15.000
gpd.
You must indicate either-yes" or"no" to each of the following`.
(7hc following criteria apply to large-systems in addition to the criteria above)
yes nol
�/ the system is within 400 feet of a surface drinking water supply
_ 6' the system is within 200 feet of a tributary to a surface drinking water supply
± the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA)or a mapped
Zone 11 of a public water supply well
!f 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
s:entficant threat under Section E or failed under Section D shall upgrade the system in accordance with 3'10 CMR
30- The system owner should contact the appropriate regional office of the Deparrment.
4
Page 5 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 162 Starboard Lane
Osterville ,Mass .
Owner:Windle Priem
Date of Inspection: 6 13/0 2
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health
Were any of the system components pumped out in the previous two weeks I?
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?
141
Were all system components, a-Rccluding the SAS, located on site? '
__AI�4L Were the se tic tank manholes uncovered,opened, and the interior of the tank inspected for the condition
of the baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge and depth of scum ?
Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems ?
The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
Yes no
!�Existing information. For example, plan at'the Bo
ard of Health.
v _ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) (310 CMR 15.302(3)(b)]
5
Page 6 of
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:162 Starboard Lane
Osterville .Mass .
Owner: Windle Priem
Date of Inspection: 6/13/0 2
FLOW CONDITIONS
RESIDENTIAL "
Number of bedrooms(design): 1� Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 1 10 gpd x H of bedrooms): wle
Number of current residents: d
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system ( es or no):� (if yes separate inspection required)
Laundry system inspected(yes or no): �j
Seasonal use: (yes or no): j `
Water meter readings, if available (last 2 years'usage(gpd)): 2000-75,000 gallons-205.48 GPD
Sump pump(yes or no): �d — gal lons-871 . 24 FPD
Last date of occupancy:L�� . . LSprinkler system present .
COMMERCIALq"USTRIAL
Type of establishment: /)
Design now(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):.
Industrial waste holding tank present (yes or no): 4/4
Non sanitary waste discharged to the Title 5 system (yes or no): t!L0
Water meter readings, if available: 11 /11/4
Last date of occupancy/use: A/4
OTHER(describe):
GENERAL INFORMATION '
Pumping Records
Source of information: &IW� dN>n 5
Was system pumped as pan of the inspection (yes orno): _
If yes, volume pumped: ;0 gallons-- How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
Ald Septic tank,distribution box, soil absorption system
Single cesspool
Y9 itJeS'7'Sd±� �I—/"eri�f,Su�reS
Overflow cesspool
Id Privy • .
Shared system (yes or no)(if yes, attach previous inspection records, if any)`
ZDlnnovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be
obtained from system owner}
Tight tank N0 Attach a copy of the DEP approval
APOther(describe):
Appp"roximate ee of all o oognnents, date installed (if known) and source of information: '
Were sewage odors detected when arriving at the site (yes or no):-10
6
R
Page 7 of 1 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued) .
Property Address:162 Starboard Lane
Osterville ,Mass .
Owner: Windle Priem
Date of Inspection: 6 13 0 2
BUILDING SEWER(locate on site plan)
,,
Depth below grade.
-; !�''1 � ��SsSlll�i 1(
Materials of construction: cast iron 1/40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight no evidence of leakage . The systems
are vented through . the house vents :
SEPTIC TANIZt&&,(locate or. ite plan)
Depth below grade: AM
Material of construction: lAconcretea metaW,4 fiber glass/bolyethylene
4L,4other(explain) A)II
If tank is metal list age:4�S is age confirmed by a Certificate of Compliance(yes or no):_(attach'a copy of -
certificate)
Dimensions: /Vi9
Sludge depth: AN
Distance from top of sludge to bottom of outlet tee or baffle:_
Scum thickness: A14
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: 41i9
How were dimensions determined: /Ui¢
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of.leakage, etc.):
Septic tank is not present".
GREASE TRAP (locate on site plan) `
Depth below grade:q�f!
Material of construction: concrete, metali444fiberglass/J�polyethylenesp 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: /t/7f
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 is not present .
7
Page 8 of! I
OFFICIAL INSPECTION FORM —'NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 162 Starboard Lane
Osterville.Mass .
Owner: Windle Priem
Date of Inspection: 6/13/0 2
TIGHT or HOLDING TANK4 LI (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: AM
Material of construction: daconcrete &4 metal A&fiberglass polyethylene other(explain):
AN
Dimensions:
Capacity: AM gallons
Desien Flow: A4 gallons/day
Alarm present (yes or no):
Alarm level: Alarm in working order(yes or no): AO
Date of last pumping: _Ay_
Comments (condition of alarm and float switches, etc.):
Tight or holding tanks are not present
DISTRIBUTION BOYA"(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.):
Distribution box is not Dresent
PUMP CHAMBER4AvA (locate on site plan) P
Pumps in working order(yes or no): 41A
Alarms in working order(yes or no):�
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Pump chamber is not present
8
Page 9 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 162 Sgarboard Lane 4
Osterville ,Mass.
Owner: Windle Priem
Date of Inspection: 6/13/0 2
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
2-6 ' X8 ' block cesspools East side of house in series .
2-1000 gallon leaching pits West side of house . 6 ' X9 ' in series .
If SAS not located explain why:
Located ; See page 10 7 TTY p
leaching pits, number:
.(w leaching chambers,number:
&(Z leaching galleries,number: '
AD leaching trenches,number, length:
A/bleaching fields,number, dimensions: 6 .
overflow cesspool, number: J i-'i& /f
innovative/alternative system Type/name of technology. 11�,-)1;,A .,JP G P�
Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,
etc.): - -
Loamy boney .sand to medium fine sand . No signs of hydraulic
fa; lurP or nonding . VEigetarion is normal Pits dry Overflow ,
cesspool dry at time ; of inspection ,
CESSPOOLS: cesspool ust be pKa/ped as part of inspection)(locate on site plan)
Number and configuration;
Depth—top of liquid to in invert: l
Depth of solids layer: 6� ,
Depth of scum laver:
Dimensions of cesspool: f�
Materials of construction:
Indication of groundwater inflow(yes or no): (,Z
Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation;etc'.):
Same as above .
PRIVY,I1,(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.):
Privy is not . present ,
9
Pagc 10 0(11
OFFICLAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM 1NFORM.ATION (continucd)
Pfoperrry Aodre,,l62 } Starboard Lane
Ostervi e , ass .
Owocr: Ili ndl P Priem
Dstc of ln,pcctioo: 6 /1 3/62
i
SKETCH OF SEWACE DISPOSAL SYSTEM
ho.ioc a tkctch of the tcwsjc oitpotsl system including tics to tl
oc l Iced rWo ptrmencnt re(crcncc IenCmarx, o
ncrvnt k, Loc. „< ,rt �<ils wilhih 100 (cct. Locctc whcco public witcr-supply cntcrs the bviloing.
_
27
/A
/ N
d
N O, kAl
10
Page I I of 11
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 162 Starboard Lane
Osterville ,Mass .
Owner:Windle Priem
Date of Inspection: 6/13/0 2
SITE EXAM
Slope w
Surface water
Check cellar
Shallow wells
Estimated depth to ground water A -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:e
served site abuttin roe / bservation hole within 150 feet of SAS)
hecked with local Board of Health-explain: ,4)A
Checked with local excavators, installers-(attach documentation)
Accessed USGS databas5explain: h t t p : 11 t o w n b a r n s t a b 1 e .ma u s .
You must describe how you established the high ground water elevation:
Used ; Gahrety & Miller Model 12/16/94 Water t-ahla elevatinng aho„A sea level .
Used ; USGS ; ObaeFvatiea well dat-arty- 1992
Used ; USGS ; TeGhnieal l�t�l� 99
of the water table eleycitions.
Leaching
Pit JI. :eet
Groundwater.' Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Fnmpter Method
Therefore, the vertical separation distance between the bottom
of the leaching pit and the adjusted groundwater table is
feet. '
F R
1I
• e — _/rill
`_ rrnr+�nl•rt—.•r�+rn. mr•nirrra�.n asn.+rr,..•tr+•+v.>•:�n+en.m+rs—.+.ia rrvir+,,.r.rrs� .rnm_�•..5�-�(,'v�. .'
1 TOWN: OF Barnstable WARD. OF HEALTH
SUIISURFACF `9EHAGF DISPOSAL SYSTEM INSPECTION FORM PART D •- CERTIFICATION I+
•••T••l�T•••••..—�.11I��TI.T.TT1'.I:1!TTTT1TfTTT9'r•.'1-IIRR1tTRNrTInTCNRiRT�.IA'1�11 ,. tRI.I1 .•.�5.•r•r'I�•�. �..A
-TYPE OR PRINT CI•EARLY—
PROPERTY INSPECTED
STREET ADDRESS 162, Starboard Lane, Osterv'ille ,Mass . '
b
ASSESSORS MAP , DLOCK AND PARCEL #- 166-106
OWNER' s NAME wi nrl l P Pr,em
PART D - CERTIFICATION r
NAME OF INSPECTOR Joseph P,.Macomber Jr .
COMPANY NAME J. P.Macomber & Son Inc! '
COMPANY ADDRESS Box66 Centerville ,Mass . 02632
Street . Town or CSty state LIP
COMPANY TELEPHONE (508 1 775 - 3338,1- FAX ( 508 ) 1790 _ 1578
R ,
CERTIFICATION STATEMENT
I certify that I • have personally inspected the sewage disposaj system at
this address and that the information reported is true ,-, accurate , and
omplete as of the time of .-inspection . The inspection was performed and any
recommendations regarding •upgrRde , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems )
Check one ((�}-
System PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect `public
health or the environment as defined i'n 310 CMR 15 , 303 , Any failure
criteria not evaluated a`re :as stated in the .FAILURE CRITERIA section of
this form ,
System FAILEU$
The inspection which I have con�-cted has found that the system fails to
Protect the public health and the environment in accordance with Title
5 , 3.10 CMR 15 . 3.03 , and '.as specifically noted `on ' PART C' - FAILURE
CRITERIA of this inspection form ,
Inspector Signatu � ,�
Date
ne copy of thi ertlfication must be provided to the OWNER, the BUYER'', '( where applicable ) and the 130ARD OF 1tEALT'll.
* If the inspection PAILED , the owner or "operator shall upgrade ' th.e ayetem
within one year of the date of the inspection , unless allowed .or 'required
otherwise as provided in 310 CHR 15 . 305 , -
partd .doc
y COMMONWEALTH OF MASSACHUSETTS
Z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTI
� Vy
1,y sa•. Oct
TITLE 5
OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY:ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM FORM
PART A
CERTIFICATION
Property Address:
Owner's Name: I PARCEL e O
.Owner's Address: IIA—V
. so �o �, LOT
Date of Inspection:_',rls�!�CLl;)
Name of Inspector: (please print) +
Company Name.'`
.Mailing Address: r_Sf
Telephone Numb 9
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 M000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Si nature: — Date: ?k �-
Insp -Signature:
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.
Notes and Comments
****This report only,describes conditions at.the time of inspection and under the conditions of use,at that
time.This inspection does not address how the system will perform in the future under the same or different.
conditions of use.
Title 5.Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
A
Owner: _p1h.
Date of Inspection: _ W
Inspection Summary: Check A,B,C;D or E/ALWAYS complete.all of Section D
A. -Syystem Passes:
V =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•.,,..1 �`t
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:
2
Page 3 of 71
OFFICIAL )INSPECTION FORM -.NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE.SEWAGE.DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property-Address: zJ � Ad1-�fi/LN A` Q/rC.o
Owner: 7T'
Date of Inspection: �e
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 CiVIR 15.303(1)(b)that the
system is not-functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering.vegetated wetland or a salt marsh
Z. ` System will fail unless the Board of Health (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 we1L
_ 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:
3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY`ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: '
✓U.�l
Owner: 0,0 ,A0
Date of Inspection:
2
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
Dischar$eor.ponding of effluent to the surface of the ground or surface waters due to an overloaded or.
Jclogged SAS.or cesspool
static,liquid aevel in the distribution box above outlet invert due to an overloaded'or clogged SAS or
l cesspool
_ _I Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number '
_ �Vof times pumped
Any portion of the SAS, cesspool or privy is below high ground water elevation.
v Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
� water supply.
. Any portion of a cesspool or privy is within a Zone 1 of a:public well.
t�Any portion of a cesspool or privy is within 50 feet of a.private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. (This system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence*of ammonia
nitrogen and nitrate nitrogen is equal to or less than pprn,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form:]
y f
(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 10000 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-I WPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any questibn in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 1.1
OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 5� ..
bklA
Owner: ��-
Date.of Inspection:_ 2 s�2h�
Check if the following have been done.You must indicate"Yes"or"no"as to each of the following:
Yes No R
_�_ 'Pumping.information
.was provided by the owner,occupant, or Board of Health
i/ 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?
V' 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?
i' Was.the facility owner(and occupants if different from owner)'provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
Existing information.For example,a plan.at the Board of Health.
— Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)]
5
Page 6 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner: Y�2�
Date of Inspection: S a(�Ua
FLOW CONDITIONS
RESIDENTIAL✓
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (fqr example: 11.0 gpd x#of bedrooms):� o
Number of current residents:
Does residence have a garbage grinder(yes or no):
�
Is laundry on a separate sewage system ( es or no)P,[if yes separate inspection required]
Laundry system inspected(yes or no)��
Seasonal use: (yes or no
Water meter readings, i &ailablef (last 2 years usage(gpd)): 00
Sump pump(yes or n :
Last date of occupancy:_ mc, A&u )v %"
COMMERCIAL/INDUSTRIAL ,
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft;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:
Was system pumped as part of the in pect' yes or 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)
—Tight tank _Attach a copy of the DEP approval
Other:(describe):
proximate a e of all components, date installed(if known)and source of information:
v '
Were sewage odors detected when arriving at the site(yes or no):
6
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM.INFORMATION(continued)
Property Address: �
Owner: 'tip die
Date of Inspection: /nFi'LP/u 04,�>G 6
BUILDING SEWER(locate on site planulx&
Depth below grade:
Materials of construction;_cast iron _40 PVC_other(explain):
Distance from private water supply well or suction line: y
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 TRA�Wocate 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.):
Page 8 of 11
OFFICIAL INSPECTION FORM-=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C .
SYSTEM INFORMATION(continued)
Property Address:
A
Owner:
Date of Inspection:
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;gjj,_(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)
( P )
i
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.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARYASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM.INFORMATION(continued)
Property Address
A
Owner:
Date of Inspection: 0 „2�i>w
SOIL ABSORPTION SYSTEM(SAS): ✓locate on site plan,excavation not required)
If SAS not located explain why:
4 ,
Type
.................
leaching pits,number:_
leaching chambers,number:
Leaching galleries,.number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:—Q--
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure; level of ponding,damp soil,condition of vegetation,
etc.):
CESSPOOLS: Z(cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: G� _ (�`X ' 2.rot..e'Ai
Depth--top of liquid to inlet inv'ert:
Depth of solids layer:_
Depth of scum layer: .
Dimensions of cesspool: 9
Materials of construction:
Indication of.groundwater inflow(yes or no). j
C mments(note conditio of soil, §gns of hydraulic failure, level of ponding,co dition of vegetation,etc):
RIO 62
PRIV (locate on site plan) AAO ( ] Poe
Materials of construction:
Dimensions: _
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc):
k err �{ -fit/ IO � � q4wl
9
Page 10 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY-ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: r a
"a
Owner: A ��va
Date of Inspection:
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.
.00
L7I
D-7
_�
e
�a
10
Page 11 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSUT:FACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: (po
Owner:
Date of Inspection , a
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells 3.
Estimated.depth to ground water feet
Please indicate(check).all methods used to determine the high:ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
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:
11
armit NUiiluel': /IJoc?'
Completed qJ'.:._ //tom."f,
?'G "G:,O•Ul\JD LEVEL C.OMPU I,-^"NON
Site Location: ��/� 5 �'/� �G�L� `S�/ rcJ� �� ' LO- N�o•.
Own er 9ff,?/'� Address--
Contractor:—Alpf- 02_11-5,7" Address: 7 r ld� /" �✓ �/Q,
STSc? 1 Nleasuredeotb C•W'aTcrtabi
a
to Ilea
..................... .................................. .Date v.
no�cn/day/year I
S T._° 2 Usinc.Waier-Level.range Zone ;
and bide-We'll:442p.10cate
• � site�and�•decermi'ne: -, � � '."
O.•kppro.pri ate.Jndex werl................ ...-..........._.........-._.......
J. (:
UWa ..- lever,:n Torre:-..........
- 1: . .. • is � �• ..
J; -y�•:..�i:'. UslnL_'—mo+'+ishiV.r=pJ.r.-,"Curr nt
• Water �es�+ui:ces�Co.nditions" .. i
determine curs ens depth Lo Q
water revel 7or'Inc`!3x wel-I .................... 91�
: ear
?__`" Usinc.Ta�ie.O:;,afl�t=r-Level Adjustments
TOr index'weil (STEP 2A;,;current de;oth
to water level for.index well (STEP 3},
i
and•wacer-level zone (ST�P 2B}
de rmi'.ne-water level adius-tmerrt .......................
STEP-. 5 Stimaze•Ctept3 t0:hiah water
. DySUhtiactira ti?.e•wateF .
level adjustman (S:I EP 41
'from iT Eaf:u.fed.depin O Watei
cam_
level"a..site.(S I E l) _..........__............._............:....-.........................._.....-....-........._. �4✓/
Il;ure !V:��:�vt I•V��.I'Jl�ly"vtii l.�4:'::. •.
Iv
COMMON WEALTI I OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
- - DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (fill) 292-5500
TRUDY COXF,
350 MAIN STREET Secretary
ARGEO PAUL CELLUCCI WEST YARMOUTH, MA DAVID R. STRUIIS
Governor �O 508-775-2800 Commisainner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
MAP PAR
PROPERTY ADDRESS: 162 STARBOARD LANE, OSTERVILLE ADDRESS OF OWNER:
DATE OF INSPECTION: FEBRUARY 22, 2000 RALPH NICHOLS
NAME OF INSPECTOR : JAMES D. SEARS
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 9310 CMR 15.000)
COMPANY NAME: A$B Canco
MAILING ADDRESS: 350 Main Street,West Yarmouth,MA 02673
TELEPHONE NUMBER: (508)775-2800
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,
accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper
function and maintenance of on-site sewage disposal systems. The system:
X PASSES
CONDITIONALLY PASSES
NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY
FAILS
INSPECTORS SIGNATURE: LDATE: FEBRUARY 24,2000
CIX
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) 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.
NOTES AND COMMENTS:
TWO SYSTEMS, ONE FOR WASHER, ONE FOR MAIN HOUSE. MAIN SYSTEM IS WORKING, MAIN SYSTEM
IS BLOCK AND OVER 25 YEARS OLD.
SITE OVER ALL PASSES,INSPECTION OF SYSTEM IS BASED ON CONDITION OF SYSTEM AT THE TIME
OF THE INSPECTION.THERE IS NO GUARANTEE ON THE LIFE OF THE SYSTEM.
o G
V., ro
� o
revised 9/2/98 1 I
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIVICATION (continued)
Property Address: 162 STARBOARD LANE,OSTERVILLE
Owner: NICHOLS, RALPH
Date of Inspection: FEBRUARY 22,2000
INSPECTION SUMMARY: Check A, B, C, orD:
A] SYSTEM PASSES: X
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR
15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
B SYSTEM CONDITIONALLY PASSES: N/A
One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The
System,upon completion of the replacement or repair,as approved by the Board of Health will pass.
Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not)
The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate
Of Compliance(attached)indicating that the tank was installed within twenty(20) years prior to the date of the
inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or
exfiltration,or tank is 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.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s)or due to a broken,settled or uneven distribution box. The system will pa
pass inspection if(with approval of the Board of Health).
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
The system required pumping more than four times a year due to broken or obstructed
pipe(s). The system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
revised 9/2/98 - 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 162 STARBOARD LANE,OSTERVILLE
Owner: NICHOLS, RALPH
Date of Inspection: FEBRUARY 22,2000
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N/A
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 IN ACCORDANCE WITH 310 CMR 15.303
(1)(b)THT 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 ANY)
DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system(SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone
1 of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet
of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100
feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility
and the presence of ammonia nitrogen and nitrate nitrogen and is equal to or less than 5 ppm. Method
used to determine distance (approximation not valid).
3) OTHER
t-
revised 9/2/98 3
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 162 STARBOARD LANE, OSTERVILLE
Owner: NICHOLS, RALPH
Date of Inspection: FEBRUARY 22,2000
D] SYSTEM FAILS: N/A .
You must indicate either"Yes"or"No" to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR
16.303. 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.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged
SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an over-
loaded or clogged SAS or cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged
SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow .
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s)
Number of times pumped
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater
elevation.
Any portion of a cesspool or privy is within 100 feet of surface water supply or tributary to a
surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private
water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach
copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate
nitrogen.
E) LARGE SYSTEM FAILS: N/A
You must indicate either"Yes"or"No"as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a
significant threat to public health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or
mapped Zone II of a public water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local
regional office of the Department for further information.
revised 9/2/98 4 a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 162 STARBOARD LANE,OSTERVILLE
Owner: NICHOLS, RALPH
Date of Inspection: FEBRUARY 22, 2000
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health.
X 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.
N/A As built plans have been obtained and examined. Note if they are not available with N/A.
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout.
X All system components,including the Soil Absorption System,have been located on the site.
X 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:
X Existing information.Ex.Plan at B.O.H.
X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation
of distance is unacceptable)11 5.302(3)(b)] ,
X The facility owner(and occupants,if different from owner)were provided with information on
the proper maintenance of Sub-Surface Disposal System.
revised 9/2/98 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 162 STARBOARD LANE,OSTERVILLE
Owner: NICHOLS, RALPH
Date of Inspection: FEBRUARY 22, 2000
FLOW CONDITIONS
RESIDENTIAL:
Design flow: "0 g.p.d./bedroom for S.A.S.
Number of bedrooms(design) 4 Number of bedrooms(actual): 4
Total DESIGN flow N/A
Number of current residents: 1
Garbage grinder(yes or no): YES
Laundry(separate system) (yes or no): YES If yes,separate inspection required
Laundry system inspected(yes or no): YES
Seasonal use(yes or no) NO a
Water meter readings,if available(last two(2)year usage(gpd): 1998109,000/1999 65,000
Sump Pump(yes or no): NO
Last date of occupancy: N/A
COMMERCIAL/INDUSTRIAL: r
Type of establishment:
Design flow: Gpd(Based on 16.203)
Basis of design flow
Grease trap present:(yes or no):
Industrial Waste Holding Tank present:(yes or no)
Non-sanitary waste discharged to the Title 5 system:(yes or no)
Water meter readings,if available:
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
N/A
System pumped as part of inspection:(yes or no) YES
If yes,volume pumped: 800 gallons
Reason for pumping PART OF INSPECTION
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system 4
X cesspool
X Overflow cesspool
Privy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
I/A Technology etc.Attach copy of up to date operation and maintenance contract.
Tight Tank Copy of DEP Approval
Other LAUNDRY SYSTEM TWO(2)PRE CAST PITS
APPROXIMATE AGE of all components, date installed (if known)and source of information:
AROUND 25 YEARS
Sewage odors detected when arriving at the site:(yes or no) NO,
revised 9/2/98 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 162 STARBOARD LANE, OSTERVILLE
Owner: NICHOLS, RALPH
Date of Inspection: FEBRUARY 22,2000
BUILDING SEWER: N/A
(Locate on site plan)
Depth below grade:
Material of construction _ cast iron _ 40 PVC _ other(explain)
Distance from private water supply well or suction line
Diameter
Comments:(condition of joints,venting,evidence of leakage,etc.)
SEPTIC TANK: N/A „-
(Locate on site plan)
Depth below grade:
Material of construction X concrete _ metal _ Fiberglass Polyethylene _ other(explain)
If tank is metal,list age Is age confirmed by Certificate of Compliance (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 dimensions were determined
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: N/A
(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:
(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 9/2/98 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 162 STARBOARD LANE, OSTERVILLE ,
Owner: NICHOLS, RALPH
Date of Inspection: FEBRUARY 22,2000
TIGHT OR HOLDING TANK: N/A (Tank must be pumped prior to,or at time,of inspection)
(Locate on site plan)
Depth below grade:
Material of construction _ concrete _ metal _ Fiberglass _ Polyethylene _ other(explain)
Dimensions:
Capacity: Gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm in working order Yes; No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX: N/A
(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: N/A
(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.)
revised 9/2/98 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 162 STARBOARD LANE, OSTERVILLE
Owner: NICHOLS, RALPH
Date of Inspection: FEBRUARY 22, 2000
MAIN HOUSE SEPTIC SYSTEM
SOIL ABSORPTION SYSTEM (SAS): X
(locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not located, explain:
Type:
Leaching pits,number:
Leaching chambers,number:
Leaching galleries,number:
Leaching trenches,number,length:
Leaching fields,number,dimensions:
Overflow cesspool,number, 1
Alternative system:
Name of Technology:
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.).
OVERFLOW POOL DRY.6'DEEP,CEMENT COVER 4"BELOW GRADE.
CESSPOOLS: X
(locate on site plan)
Number and configuration: 1
Depth-top of liquid to inlet invert: 20"
Depth of solids layer: 6"
Depth of scum layer: 011
Dimensions of cesspool: 6'
Materials of construction: BLOCK
Indication of groundwater: NO
inflow(cesspool must be pumped as part of inspection)
Comments::
(note condition of soil,signs of hydraulic failure, ,level of ponding,condition of vegetation,eta.)
MAIN POOL AT WORKING LEVEL,ONE INLET NO TEE,ONE OUTLET WITH TEE,CEMENT COVER 16"BELOW GRADE.
PRIVY: N/A
(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 9/2/98 9
PART C
SYSTEM INFORMATION (continued)
Property Address: 162 STARBOARD LANE, OSTERVILLE
Owner: NICHOLS, RALPH
Date of Inspection: FEBRUARY 22, 2000
LAUNDRY SYSTEM
SOIL ABSORPTION SYSTEM (SAS): X
(locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not located, explain: '
Type.
Leaching pits,number: 1
Leaching chambers,number:
Leaching galleries,number:
Leaching trenches,number,length:
Leaching fields,number,dimensions:
Overflow cesspool,number, 1
Alternative system:
Name of Technology:
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
MAIN PIT AT WORKING LEVEL,COVER 4"BELOW GRADE.OVERFLOW PIT DRY,WALLS CLEAN.COVER 4"BELOW
GRADE.
CESSPOOLS: N/A +
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool
Materials of construction:
Indication of groundwater.
inflow(cesspool must be pumped as part of inspection)
Comments::
(note condition of soil,signs of hydraulic failure,,level of ponding,condition of vegetation,etc.)
PRIVY: N/A
(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 9/2/98 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 162 STARBOARD LANE, OSTERVILLE
Owner: NICHOLS,.RALPH
Date of Inspection: ° FEBRUARY 22, 2000
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'(locate where public water supply comes into house)
113, ;1
O
revised 9/2/98 11
n �
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 162 STARBOARD LANE, OSTERVILLE.
Owner: NICHOLS, RALPH
Date of Inspection: FEBRUARY 22 2000
NRCS Report name
Soil Type
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Ground water depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to groundwater 30+ Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
X Observation of Site(Abutting property,observation hole,basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators,installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(Must be completed)
NOTE: LOT HIGH AREA WELL ABOVE GROUNDWATER.
revised 9/2/98 12
t
TOWN OF BARNSTABLE
GrQCAT10N .1,K%1 SEWAGE #
VILLAGE ®�' f /.�.�P. �. ASSESSOR'S MAP & LOT
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INSTALLER'S NAME&PHONE'NO.
SEPTIC TANK CAPACITY40J��
LEACHING FACILITY: (type (size)
s OF
NO. OF BEDROOMS
BUILDER OR OWNER .�
PERMITDATE: 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 L ching Facility (If any wetlands exist
within 300 fe c ility) Feet
Furnishe by e
all
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LOCATION &9 5Z/ r �/+o SEWAGE #
VILLAGE 0 S 7- ASSESSOR'S MAP LOT
J®v.S 9,fc o Ps
'S NAME Cz PHONE NO. A & B CANCO 775-6264
SEPTIC TANK CAPACITY
LEACHING FACILITYAtype) - (size)
NO:OF BEDROOMS PRIVATE WELL,'OR�PUBLIC WATER
BUILDER OR �� �l�/� C//o L S
yS°P£c�
DATE P9R=Td96HRDc3 ®o
DATE COMPLIANCE ISSUED:
jsPiS�£C /
VARIANCE GRANTED: Yes No
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