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Home My WebLink About0329 SWIFT AVENUE - Health 329 SWIFT AVE. OSTERVILLE A 166 016 - �I I s I Commonwealth of Massachusetts 07& u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 329 Swift Ave co Property Address f Ann Rosseel Owner Owner's Name information is X required for every osterville MA 02655 7-28-17 _ page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:when filling out forms A. General Information c on the computer, o` �P��\A OF MAS use only the tab �. 1. Inspector: S •.9c key to move your ��; •,y cursor-do not James D.Sears - _ :' JAMES .:m+ use the return key. Name of Inspector EARS :CO.- Capewide Enterprises Company Name 153 Commercial Street '''•,F 5 IN Company Address Mashpee MA .02649 Cltyrrown State Zip Code 508-477-8877 S 1623 Telephone Number License Number B. Certification certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 8-3-17 pector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving.Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the-approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage/Disposal System•Page 1 of 17 F O VS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 329 Swift Ave Property Address Ann Rosseel t Owner Owner's Name information is required for every Osterville MA 02655 7-28-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. ` Comments: The system is a 1500 Gal. Tank D Box and two chambers. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins:doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 329 Swift Ave Property Address Ann Rosseel Owner Owner's Name information is required for every Osterville MA 02655 7-28-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explairi below): . ❑ The system required.pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ 'Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 329 Swift Ave Property Address . Ann Rosseel Owner Owner's Name information is required for every Osterville MA 02655 7-28-17 page. City/Town State Zip Code Date of Inspection, B. Certification (cont.) 2. System will fail unless the•Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ' ❑ The system has a septic tank and SAS and the.SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes .No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in BEER= is less than 6" below invert or available volume is less than 1/day flow e%l/aG t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 329 Swift Ave Property Address Ann Rosseel Owner Owner's Name information is required for every Osterville MA 02655 7-28-17 page. City/Town State Zip Code Date of Inspection- B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the'last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑. the system is within-200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area_IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section.E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate 1 regional office of the Department. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 329 Swift Ave "M ' Property Address Ann Rosseel Owner Owner's Name information is required for every Osterville MA 02655 7-28-17 page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information.was provided by the owner;occupant,or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water,been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the'site inspected for signs of breakout? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 329 Swift Ave Property Address - Ann Rosseel Owner Owner's Name information is required for every Osterville MA 02655 7-28-17 page. CitylTown State Zip Code Date of Inspection D. System Information Description: The system is a 1500 Gal. Tank D Box and Two Chamber's. Number of current residents: 1 Does residence have a.garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2015-81,0006als 9 ( Y g (gp )) 2016-69,000Gal's Detail: Sump pump? El Yes ® No Last date of occupancy: Present - Daatt e Commercial/Industrial Flow Conditions: Type.of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts u r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 329 Swift Ave Property Address Ann Rosseel Owner Owner's Name information is required for every Osterville MA 02655 7-28-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NA 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 c ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) El innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts RI W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 329 Swift Ave Property Address Ann Rosseel Owner Owner's Name information is required for every Osterville MA 02655 7-28-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known) and source of information: 2000 Permit # 2000-618. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): . 2' Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH - 40. Septic Tank(locate on site plan): 1411 Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ' ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) . ❑ Yes ❑ No Dimensions: 1500 Gal. Precast H-10 i Sludge depth: 2" t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 329 Swift Ave Property Address Ann Rosseel Owner Owner's Name information is required for every Osterville MA 02655 7-28-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 1 Distance from top of scum to top of outlet tee or baffle 8„ Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Asbuilt-Tape Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank and covers at 14" below grade. In and outlet tee's. No sign of leakage or over loading. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass '❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet.tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GSM 329 Swift Ave Property Address Ann Rosseel Owner Owner's Name information is required for every Osterville MA 02655 7-28-17 page. Cityrrown State Zip Code Date of Inspection Do System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass_ ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ,M 329 Swift Ave Property Address Ann Rosseel Owner Owner's Name information is required for every Osteryille MA 02655 7-28-17 page. Cityrrown State Zip Code Date of Inspection Da System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x1T-2' below grade w/cover at 10".'Box is clean and solid w/one line out. No sign of over loading or solid carry over. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note'condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: I t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 329 Swift Ave Property Address Ann Rosseel Owner Owner's Name information is required for every Osterville MA 02655 7-28-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is two 500 Gal.dry well chambers w/4' stone. Chambers at 32" below grade w/cover at 1'. Chambers are wet bottom w/clean like new wall's. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration ! Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 r Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments G M 329 Swift Ave Property Address Ann R osseel Owner Owner's Name information is required for every Osterville MA 02655 7-28-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil;signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): _ Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 4 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 329 Swift Ave Property Address Ann Rosseel Owner Owner's Name information is required for every Osterville MA 02655 7-28-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) # Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately .O O o. dq 13-1 35 A-3= °; t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts _ Z, W Title 5 Official Ins pection ection Foam Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 329 Swift Ave Property Address Ann Rosseel Owner Owner's Name information is required for every Osterville MA 02655 7-28-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells �® 10'+ Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 2000 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: T.H. 2000 10+' no G.W.. Bottom of chambers at 4' below grade. Bottom of chambers at 6' above T.H. Depth. i Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 329 Swift Ave Property Address Ann Rosseel Owner Owner's Name information is required for every Osterville MA 02655 7-28-17 page. CitylTown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ®' System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file i t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17. - COIv1I ONTWEALTH OF i�WSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFT DEPARTMENT OF ENVIRONMENTAL PRO - ONE R'INTER STREET, BOSTON MA 02108 (617)292-5 A (� TRUDY C0XE Secretary ARGEO PAUL CET LUCCI +I VAVID B. STRUHS Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR Commissioner. PART A CERTIFICATION Property Address: 3Z :�;Wl FT tq VE Name of Owner� �_ (��r� r(�� '�►�� Date of Inspection:��, VICL� I Address of Owner: �Gl�/+-' 1 . Name of Inspector:(Please Print)Wg E. rn yf0C�clJ I am a DEP approved stem inspector pursuant to Section 15.340 of Title 5(310 CHAR 15.000) Company Name: W . Mang Address: Telephone Number: 3 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 in The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage isposal systems. The system: _ Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signatur . s- Date: (Z 0b 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 Q0 v4r -71 MjEjA �t L u mt, 4v , 5L_ uu t�- C9 '� mil, lop K 1 P F:74tLi)e� revised- 9/2/98 Page Iof11 - ;j Printed on Recycled Paper - - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CER71RCATION (continued) Property Address: 32`i Owner: F-eV ffTe W►1L'TaV.l �f�' �''C.+ Date of Inspection: ` I/Ov INSPECTION SUMMARY: Check A, Q C, or D: A. SYS PASSES: Y I have not fou nd any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: �� y� B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as,approved by the Board of Health, will pass. Indicate yes, no, or not determined(Y, N, or NO). 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 failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying 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 pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): . broken pipe(s) are replaced obstruction is removed revised 9/2/98 P2ge2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A Q CERTIFICATION (continued) Property Address: 3Z/ 5�� kWAQ 6 MULF, Owner. 5 �� Date of Inspection: C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order,to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)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 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 I 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 is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER revised, _e rsed 9/2/98 P2ge3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) �•; 1�ii��/� Property Address: � 3 R FAILS: Owner: � i� !� 111��L ;�"wr Date of Inspection: / oO / D. SYSTEMLS. 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 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. Yes No Backup of sewage into facility-or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. 'T tatic 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 112 dayflow. V Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). umber of times pumped_ Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water anaivsis for coliform bacteria, volatile organic compounds,•ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: 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: 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: r Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area:IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. . revised 9/2/9'8 Page 4oril SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 2, .4;wll ( OW—ZA C Owner: F%IITZ� MI(dTD6! �C ' Data of Inspection: Check if the following have been done:You must indicate either "Yes" or "No" as to each of the.following: Yes No . / Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for-at least two weeks and-the system has been•receivingttormal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. 14`Y _ As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. / _ The system does not receive non-sanitary or industrial waste flow: The site was inspected for signs of breakout. _ All system components, excluding the.Soil Absorption System, have been located on the site. _, The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: ✓/ Existing information. For example, Plan at E.O.H. Determined in the field(if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)) The facility owner (and occupants,if different from owner) were provided with information on the proper.maintenarsce-0f SubSurface Disposal Systems. revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 3Z� �� z8'1FaQV L.L Owner: ►Ct` ��l1lr1 Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: g.p.d./bedroom. Number of bedrooms (des n):� Number of bedrooms(actual): Total DESIGN flow Garbage of current residents - Garbage grinder(yes or no): Q Laundry (separate system) (yes or no)_f-f yes, separate inspection required Laundry system inspected (y;so�no� / ' Seasonal use (yes g no): (fiaf/W �rr'�.o y Water meter readings, if av ilable (last two year's usage(gpd): Sump Pump (yes or no)AI� _ Last date of occupancy:L,.v/'1��/ COMMERCIALRNDUSTRIAL: AJ, Type of establishment: Design flow: apd ( Based on 15.203) 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 R CORD S and sourc of information: ' line, ,Z A �� 14/11 3 System pumped as part of inspection. (yes or no)NG7G If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Oingle cesspool verflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records,if any) r I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed Hf known) and source of information: Sewage odors detected when arriving at the site: (yes or no) V0 revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEMIINFORMATION(continued) property Address: W-1 AV& 06 UY1U-El 0wne►: Date of Inspection cc t BUILDING SEWER: (Locate on site plan) Depth below grade: O Material of construction. cast iron_40 PVC_other (explain) Distance fro mprivate water supply well or suction line Diameter Comments. (condition of joints, venting, evidence of lea a e,etc.) C 77M SEPTIC TANK: (locate on site pl n) r Depth below grade:_ Material of construction:_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: (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 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Addre4s: 52ri �'F }-• F, (� Owner: 7l LKJ{ � Ins Date of Inspe ction-TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade: Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensions: Capacity: gallons Design flow: 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- (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) Pumps in working order:(Yes or No) Alarms in working.order(Yes or No) Comments: r (note condition of pump chamber, condition of pumps and appurtenances, etc.) . revised 9/2/98 Pages of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: L� JtJlJlr l ' � (1 L� Owner: O IM(LTD ;S7FW�T—•'L.� Date of Inspection: � �dC7 ' SOIL ABSORPTION SYSTEM(SAS).A(,� (locate on site plan, if possible;excav Uon not required,location 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._ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) CESSPOOLS: (locate on site plan) - Number and configuration: Depth-top of liquid to inlet invert:_ Depth of solids layer: Depth of scum layer.�.�'S'�P _ #•[ , �� G��pippL �Z j �/� Dimensions of cesspool: (./ ✓ Materials of construction: (, Indication of groundwater: C7 A?,�f�y inflow (cesspool must E be um ed as art of inspection) /Q�1�/D � v n o S — Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:, (locate on site plan) Materials of construction: Depth of solids: Dimensions: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revised 9/2198 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 37 Owner: e� o/ kttLT61:4 Date of Inspection: bO SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 2 revised 9/2/98 Page 10or11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: l ' �a?�vt� Owner: TMC I�l�ll V"'( Date of Inspection: 6 /00 , NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope ` Surface water Check Cellar Shallow wells Estimated Depth to GroundwatO- 'Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record e-0/b ved Site (Abutting.property, observation hole, basement sump etc.) �V,-�D.teine d from local conditions Checked with local Board of health S,Ffecked FEMA Maps cked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) revised 9/2/98 Page 11of11 TOWN OF BARNSTABLE LOCATION 3XI Styf_d-- 11-0P• 0SJor451£WAGF. #a00C -6I VILLAGE 7OY 't ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY a LEACHING FACILITY:(type) X lao (size) 47 X AS -ab ' NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER P.l3LI_ BUILDER OR OWNER DATE PERMIT ISSUED: olilloo, DATE COMPLIANCE ISSUED•' VARIANCE GRANTED: ,Yes No a Li if c� � cSc r — q o T 7 13 Y � r No. � Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0[ppYication for Migaar *pgtem Cou5truction permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot N9. Owner's Name,Ad ress and Tel.Nq. Ass�o��ap�az�� °��I�L�Ti Installer's Namg,Address,and Tel.No. Designer's Name,Address and Tel.No. ��iaS /g/LOSS �Nl�. Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder(y� Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /��-ePi�Of l Type of S.A.S. Z -�D `3� 0�r9/iV&o Description of SOB; � a Z Y 2-�[ i�/�� 1142 Nature of Repairs or Alterations(Answer when applicable) .5 e,O ,v/L ✓ l Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss by s de2vW1110111o Signed to /0 --l2—& Application Approved byTJV414ate Application Disapproved for the following reasons Permit No. Date Issued No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ' Yes PUBLIC HEALTH DIVISION -TOWWOF BARNSTABLE., MASSACHUSETTS Application for �Digogar *pgtem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No./ �- / Owner's Name,Address and Tel.No. j 2� �S`LG/�T ��C-. C/f /�•r:�•�//�/,d Wit/ ��i✓J`t�yL�' �; Assessors Map.Tarcel Installer's Name,Address,and Tel.No Designer's Name,Address and Tel.No. Type of Building: Dwelling• No.of Bedrooms Lot Size sq. ft. Garbage Grinder4/a Other Type of Building lZe- S • No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day Calculated daily flow gallons. Plan Date Ic-2 Number of sheets Revision Date Title Size of Septic Tank 40;, Type of S.A.S. 2-- -5- L°'--> Description of Soil -'9 i 2 y y��e Nature of Repairs or Alterations(Answer when applicable) �5 UJ S s7/�• L-! 'C�O�' Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-sitesewage disposal system in accordance with the provisions of Title ,of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been is d by is and Heap. Signed L— L o ate Application " 'GU Application Approved by 2'f/ Date Application Disapproved for the following reasons Permit No. Date Issued ———————————————————————— - -——————————-- - THE COMMONWEALTH OF MASSACHUSETTS ` BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CEWIFY that tthhe, On-si. Sewage Disposal System Constructe3( )Repaired( )Upgraded( ) Abandoned( )by t':. i _ 1 � Cv at e5;1S as been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit N(-&A-90 �1S dated Installer G2ll/� �/ .+�s�• Designer / At n The issuance of this permit spall not be construed as a guarantee that the sy-Stem will function,as designed. �f Date l /I Q a I 0 0 Inspector - n, VV No. 02 -1 T------------------------Fee !i lJ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS lwiopogaf *pgtem Construction Permit Permission is hereby granted to Construct(/'�)Repair( )Upgrade )Abandon( ) System located at 3 2 �Gr//T f t ill/e S �i.✓i��e� and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. 10 Provided: Con must b c mpleted within three years of the date this qi 't.� Date: /�'j Approved b I _ n 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I, �, hereby certify that the application for disposal works construction permit signed by me dated�!� — `3`�G17 , concerning the property located at .3�1'p -'f�w Iel— fj► - C�//I/?neets all of the following criteria: J. This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. V • There are no wetlands within 100 feet of the proposed septic system V • There are no private wells within 150 feet of the proposed septic system • There is no increase in flow and/or change in use proposed U • There are no variances requested or needed. I • The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] v' If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen (14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation (using GIS information) B) G.W.Elevation +the MAX.High G.W.Adjustment. _ DIFFERENCE BETWEEN A and B SIGNED : / `!�/ �=; L v�� DATE: [Please Sketch proposed plan of system on back]. NOTICE Based upon the above information, a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:cert \--`�� f( � i' TOWN OF BARNSTABLE LOCATION 30 GE (�(o VILLAG ASSESSOR'S MAP 6z LOT INSTALLER'S NAME & PHONE NO. z J J iS 6EOOV/5 ric-)C-t. SEPTIC TANK CAPACITY L EACI�jNG FACII.ITY:(tgpe) (size) 0 rA� terl� NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER Pyi3LlL BUILDER OR OWNER DATE PERMIT ISSUED: I DATE COMPLIANCE ISSUED: 00 VARIANCE GRANTED: Yes No _ g t,e .. a ------------