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HomeMy WebLinkAbout0115 CAMMETT WAY - Health 115 Cammett Way Centerville - - A= 099-040 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 115 Cammett Way, Marstons Mills Property Address Jeff Platner _ Owner Owner's Name information is required for every Marstons Mills MA 02648 October 8, 2009 _ page. City[Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important:When filling out forms A. General Information on the computer, O use only the tab 1. Inspector: key to move your cursor-do not Troy Williams use the return key. Name of Inspector Troy Williams Septic Inspections _ It�l Company Name 19 Hummel Drive Company Address e�,rz South Dennis MA 02660 City/Town State Zip Code (508) 385-1300 S1682 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems: I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority �a +w co October 8, 2009 per_ Inspector's Signal a �— Date t/1 c — The system inspector shall submit a copy of this inspection report to the Approving Authority(Board O 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 c:,^. 7 O N rep�oLto 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. L ► D 115 Cammett Way,Mftons Mills•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•P ge 1 of 15 l i Commonwealth of Massachusetts r Title 5 Official Inspection Form 'w Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . 115 Cammett Way,-Marstons Mills Property Address Jeff Platner Owner Owner's Name information is Marstons Mills MA 02648 October 8, 2009 required for every — —� _ page. CityfFown 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: ® 1 have not found any information which indicates that any of the failure criteria described r in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System meets minimum standards set by Mass DEP at the time of inspection only. This inspection is not a guarantee or warranty on the future working conditions of leach ing,_pipes or components. — 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: N/A ❑ 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 115 Cammett Way,Marstons Mills•03/08 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 Cammett Way, Marstons Mills _ Property Address Jeff Platner Owner Owner's Name information is Marstons Mills MA 02648 October 8 2009 required for every � , page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: N/A ❑ 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: N/A C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑. The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 115 Cammett Way,Marstons Mills•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M r 115 Cammett Way, Marstons Mills Property Address Jeff Platner Owner Owner's Name information is required for every Marstons Mills MA 02648 October 8, 2009 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: N/A **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: N/A D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ '® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow El ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 115 Cammett Way,Marstons Mills-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 Cammett Way, Marstons Mills Property Address Jeff Platner Owner Owner's Name information is required for every Marstons Wils MA 02648 October 8, 2009 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® 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. l 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 El ® the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 115 Cammett Way,Marstons Mills•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts rz Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 115 Cammett Way, Marstons Mills Property Address Jeff Platner Owner Owner's Name information is required for every Marstons Mills MA 02648 October 8, 2009 page. City/Town State Zip Code Date of Inspection C. Che cklist 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 backup? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 115 Cammett Way,Marstons Mills•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .�' 115 Cammett Way, Marstons Mills Property Address Jeff Platner Owner Owners Name information is required for every Marstons Mills MA 02648 October 8, 2009 page. Citylrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd Number of current residents: 3 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system?[if yes separate inspection, required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 08=66,000gals g ( y g (gpd))-. 07=71,000gals Sump pump? ❑ Yes ® No Last date of occupancy: Occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: N/A Design flow(based on 310 CMR 15.203): N/A Gauons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): N/A Grease trap present? ❑ Yes ® No Industrial waste holding tank present? ❑ Yes ® No Non-sanitary waste discharged to the Title 5 system? ❑ Yes Z No Water meter readings, if available: N/A Last date of occupancy/use: N/A Date Other(describe): N/A 115 Cammett Way,Marstons Mills•03/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts v. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 Cammett Way, Marstons Mills - Property Address Jeff Platner Owner Owner's Name information is required for every Marstons Mills MA 02648 October 8, 2009 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Last pumped on June.9, 2009 per BOH. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped- gallons How was quantity pumped determined? N/A Reason for pumping: N/A Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (if yes, attach.previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ® Other(describe): no d-box Approximate age of all components, date installed (if known) and source of information: Tank& leaching are original to home built approx. 36 years ago. Were sewage odors detected when arriving at the site? ❑ Yes ® No 115 Cammett Way,Marstons Mills•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 i I Commonwealth of Massachusetts F Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 Cammett_Way, Marstons Mills Property Address Jeff Platner Owner Owner's Name information is required for every Marstons Mills _MA _ 02648 October 8, 2009 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 18"+ Depth below grade: feet Material of construction: ❑ cast iron 40 PVC sch 30 ®other(explain): Distance from private water supply well or suction line: N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): Flushed lines and found clear at the time of inspection. Septic Tank(locate on site plan): 16"with risers to 4" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: N/A years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 5' X 9'X 6' 1000 gallon Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle 2' 8„ Scum thickness Thin Layer 6" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Probe/Measured 115 Cammett Way,Marstons Mills-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 115 Cammett Way, Marstons Mills Property Address Jeff Platner Owner Owner's Name information is required for every Marstons Mills MA 02648 October 8, 2009 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Concrete inlet and outlet tee's were present. No evidence of leakage or damage was found. Tank was not in need of pumping at this time. Grease Trap (locate on site plan): Depth below grade: N/A feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): N/A Dimensions: N/A Scum thickness N/A Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle N/A Date of last pumping: N/A Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): N/A Tight or Holding Tank tank must be pumped at time of inspection) locate on site plan): g 9 ( P P P ) ( P ) Depth below grade: N/A_ Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): N/A 115 Cammetl Way,Marstons Mills•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 Cammett Way, Marstons Mills Property Address Jeff Platner Owner Owners Name information is required for every Marstons Mills MA 02648 October 8 2009 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: N/A Capacity: N/A gallons Design Flow: N/A gallons per day Alarm present: ❑ Yes ❑ No Alarm level.' N/A Alarm in.working order: ❑ Yes ❑ No Date of last pumping: N/A Date Comments (condition of alarm and float switches,etc.): N/A *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): No d-box present Pump Chamber(locate on site plan): Pumps in working order: El Yes ❑ No Alarms in working order: ❑ Yes ❑ No 115 Cammett Way,Marstons Mills•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 Cammett Way, Marstons Mills Property Address Jeff Platner Owner Owner's Name information is required for every Marstons Mills MA 02648 October 8, 2009 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): N/A Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: N/A Type: ® leaching pits number: 1-6'x6'pitw/2'stone ❑ leaching chambers number. ❑ leaching galleries number: ❑ leaching trenches number, length.- El leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil was sandy. Leach pit was found with water level approx. 1.6' below inlet invert with walls found clean above water level. No evidence of hydraulic failure or problems in the past was found at the time of inspection. 115 Cammelt Way,Marstons Mills-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts v. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments >y 115 Cammett Way, Marstons Mills Property Address Jeff Platner Owner Owner's Name information is required for every Marstons Mills MA 02648 October 8 2009 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A Depth-top of liquid to inlet invert N/A Depth of solids layer N/A Depth of scum layer N/A Dimensions of cesspool N/A Materials of construction N/A Indication of groundwater inflow ❑ Yes ® No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of.vegetation, etc.): N/A Privy (locate on site plan): Materials of construction: N/A Dimensions N/A Depth of solids N/A Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)-. N/A 115 Cammett Way,Marstons Mills•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 Cammett Way, Marstons Mills _ Property Address Jeff Platner _ Owner Owner's Name information is required for every Marstons Mills MA 02648 October 8 2009 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 't ^ Pl ' O J 13• uGwL Qps.-tir Gc�t-. 115 Cammett Way.Marstons Mills•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 r Commonwealth of Massachusetts a L Title 5 Official Inspection Form Subsurface Sewage*Disposal System Form-Not for Voluntary Assessments �M y 115 Cammett Way, Marstons Mills Property Address Jeff Platner Owner Owner's Name _ information is required for every Marstons Mills _MA 02648 October 8, 2009 page. Cityfrown State Zip Code Date of Inspection. D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water. 21.5' feet Please indicate all Methods used to determine e e the 9 high round waterelevation: ❑ Obtaindd from system design plans on record If checRed, date of design plan reviewed: Date ® Obser\Abd site (abutting property/observation hole within 150 feet of SAS) ® Check4d with local Board of Health-explain.- past inspections on file_ ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: SDW _Zone C 49.6' 5.1' adjustment You must describe`how you established the high ground water elevation: Soil was sandy. USS groundwater map shows groundwater to be approx. 26.6'. Groundwater adjustment in area al the time of inspection was 5.1' with an approx. HGWL of 21.5'. Bottom of leaching at 8.4'was found not to be located in the high groundwater elevation at the time of inspection. 115 Cammett Way,Marstons Mills-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 f �T l COMMONWEALTH OF MASSACHUSETTS z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS + d DEPARTMENT OF ENVIRONMENTAL PROTECTION 350 MAIN STREET Sa WEST YARMOUTH, JQN o 2004 508-775-2800 TOWN OF BAR NSTABLE TITLE 5 HEAL tri DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM (� � C� PART A MAP �...�. .v_ I. CERTIFICATION PARCEL.. ; �4 MAP 099 PAR 040 - Property Address: 115 CAMMETT WAY LOB` MARSTONS MILLS,MA 02648 Owner's Name: SMITH,CORRINE Owner's Address: It 5 CAMMETT WAY MARSTONS MILLS,MA 02648 Date of Inspection DECEMBER 1,2003 Name of Inspector:(please print) JAMES D.SEARS Company Name: A&B Canco Mailing Address: 350 Main Street West Yannouth,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 the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ./ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(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 tot he 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 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 115 CAM METT WAY MARSTONS MILLS,MA 02648 Owner: SMITH,CORINE Date of Inspection: DECEMBER 1,2003 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: 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. 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 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: Title 5 Inspection Form 6/15/2000 2 Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 115 CAMMETT WAY MARSTONS MILLS,MA 02648 Owner: SMITH,CORINE Date of Inspection: DECEMBER 1,2003 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 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 salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Title 5 Inspection Form 6/15/2000 3 I Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 115 CAMMETT WAY MARSTONS MILLS,MA 02648 Owner: SMITH,CORINE Date of Inspection: DECEMBER 1,2003 D. System Failure Criteria applicable to all systems: N/A 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 N/A Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than'/2 day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone 1 of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A 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 or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) NO (Yes/No)The system fails. I have detennined 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: N/A To be considered a large system the system must service a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well. If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system is 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. Title 5 Inspection Form 6/15/2000 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 115 CAMMETT WAY MARSTONS MILLS,MA 02648 Owner: SMITH,CORINE Date of Inspection: DECEMBER 1,2003 Check if the following have been done. You must indicate"yes"or"no"as to each of the following Yes No ✓ Pumping infonnation was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? J Has the system received nonnal flows in the previous two week period? J Have large volumes of water been introduced to the system recently or as part of this inspection? J Were as built plans of the system obtained and examined?(If they were not available note as N/A) J Was the facility or dwelling inspected for signs of sewage back up? J Was the site inspected for signs of break out? J Were all system components,excluding the SAS,located on site? J 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)has been determined based on: Yes No J Existing infonnation. 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)] I Title 5 Inspection Form 6/15/2000 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 115 CAM METT WAY MARSTONS MILLS,MA 02648 Owner: SMITH,CORINE Date of Inspection: DECEMBER 1,2003 FLOW CONDITIONS RESIDENTIAL Number of Bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 330 Number of current residents: 1 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): YES Seasonal use(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): N/A Sump pump(yes or no) NO Last date of occupancy: PRESENT COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: OCTOBER 2003 Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: gallons—How was quantity pumped detenmined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,soil absorption system Single cesspool Overflow cesspool Pri vy 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 copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: UNKNOWN Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 115 CAMMETT WAY S, MA 02648 Owner: SMITH,CORINE Date of Inspection: DECEMBER 1,2003 BUILDING SEWER(locate on site plan): ✓ Depth below grade: 21" 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.): SEPTIC TANK(locate onsite plan): ✓ Depth below grade: 16" 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: 1,500 GALLON PRE CAST Sludge depth: 1" Distance from top of sludge to the bottom of outlet tee or baffle: 20" Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: 12" Distance from bottom of scum to bottom of outlet tee or baffle: 18" How were dimensions determined: ASBUILT AND TAPE Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): MAIN TANK AT WORKING LEVEL.TANK AND COVERS 16"BELOW GRADE.INLET BAFFLE,OUTLET BAFFLE.NO SIGN OF OVERLOADING OR LEAKAGE. GREASE TRAP(located on site plan) N/A 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.): Title 5 Inspection Form 6/15/2000 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 115 CAM METT WAY MARSTONS MILLS MA 02648 Owner: SMITH,CORINE Date of Inspection: DECEMBER 1,2003 TIGHT or HOLDING TANK: N/A (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: N/A (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: 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.): Title 5 Inspection Form 6/15/2000 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 115 CAM METT WAY MARSTONS MILLS,MA 02648 Owner: SMITH,CORINE Date of Inspection: DECEMBER 1,2003 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1 leaching chambers,number: leaching galleries,number leaching trenches,number,length leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) LEACHING IS ONE 1,000 GALLON PRE CAST PIT.PIT AND COVER 26"BELOW GRADE.NO SIGN OF OVERLOADING OR SOLID CARRYOVER.WALLS CLEAN. CESSPOOLS: N/A (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 or no): 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.) Title 5 Inspection Form 6/15/2000 9 Page 9 of'I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 115 CAMMETT WAY MARSTONS MILLS,MA 02648 Owner: SMITH,CORINE Date of Inspection: DECEMBER 1,2003 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two pennanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. tY G 3y- 0 Title 5 Inspection Form 6/15/2000 10 Page 1 1 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Properh,Address: 115 CAM METT WAIF MARSTONS MILLS,MA 02W Owner: SMITH,CORINE Date of Inspection: DECEMBER 1,2003 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to no groundwater 4 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: ./ Observation 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: HAND DUG TEST HOLE 12' NO WATER. TEST HOLE 4' BELOW BOTTOM OF PIT. Cq, �o7 Psi N ;V �— Title 5 Inspection Form 6/15/2000 11 IL r COMMONWEALTH OF MASSACHUSETTS i EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS j DEPARTMENT OF ENVIRONMENTAL PROTECTION . . MAP PARCEL, LOT TITLE 5 OFFICIAL INSPECTION.FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: aa _6 Owner's Name: Owner's Address: Date of Inspection: O 3 Name of Inspector: pleas print) �f-E-�T, 1. 2003 Company Name: � ��- Mailing Address: TO�JHEALTH DEPN OF T BLE Telephone Number:,G •`/ -q899 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 t Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs.Further Evaluation by the Local Approving Authority ails Inspector's Signature: Date: t'/ -xa" 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.approvi.ng authority. -••• Notes and Comments _4 ..•_- ****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 I Page 2`of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 0,Property Address: A Owner: Date of Inspection: Inspection.Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A.^ /System 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: 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 ofsewage-backup br'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 f Page 3 of Il 4 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: 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 public:health, safety, or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which.will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ 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 1 Page 4 of I I OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: GC Owner: &76 g-�4 Date of Inspection p,__50(,� D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes N Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or / clogged SAS or cesspool Static liquid level in the distribution'box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less.than'/z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number / of times pumped ✓! Any portion of the SAS,cesspool or privy is below high ground water elevation. V Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface J 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. L Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well-with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen.is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NOO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to.correct the failure. E. Large Systems: To be considered a large'system the system must serve a facility with a-design flow of 10,000.gpd to.15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.364. 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 INSPECTIONFORM P,ART B .: CHECKLIST Property Address: Jkk 44 Owner:&V A L/, Date of Inspection: e, S2Q 0x0_? 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? _ _L/Has the system received normal flows in the previous two week period? Have large.volumes of water been introduced to the system recently or as-part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for.signs of sewage back up Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions,depth of liquid, depth.of sludge and depth of scum? Was.the facility owner(and occupants if different from owner).provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes/ no - Existing information.For example, a plan.at the Board of Health. t/ Determined in the field if an of the failure criteria related to Part C is at issue approximation of distance . ( y PP is unacceptable) (310 CMR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL-INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURYACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property ddress: /5 A Owner: Date of.Inspection: :Do 000 3> / FLOW CONDITIONS RESIDENTIAL ✓ Number of bedrooms(design): .2j. Number of bedrooms(actual): . DESIGN flow based on 310 CvIR 15.203 (for example: 11:0 d x#of bedrooms): 3 gp ) Number of current residents: Does residence.have.a garbage grinder(yes or no): " Is laundry on a separate sewage system (}des or-no)Wfifyes separate inspection required] Laundry system inspected y, s or no). (� Seasonal use:(yes or no): Water meter readings, if av ilable(last 2 years usage (gpd)): �`-`��,��© 1!5�17 36-lwo Sump pump(yes or no): V Last date of occupancy: o COMMERCIAL/INDUSTRIA (,{� 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 Tittle 5 system (yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Sourcel of information: Was system.pumped as part of the inspection(yes or noL.,f'o- - If yes, volume pumped: gallons--How was quantitypumped determined Reason Tor,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 DER approval __[,/Other(describe): ro n to age of all components, date installed(if known)and source of information. Were sewage odors•detected when arriving.at the site(yes or no):. 6 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: P,4 Owner: . Date of Inspection: Q01 ":�03 BUILDING SEWER(locate on site plan)� Depth below grade: Materials of construction:_cast iron 40 PVC other(explain): Distance from private waFer supply well or suction line: Comments(on condition of joints,venting,evidence of leakage, etc.): SEPTIC TANK: jZ(locate on site plan) Depth below grade: Material of construction: 6ncrete_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: 0c,k X G Sludge depth: Distance from top of slud Ye 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!cum to bottom of outlet tee or baffle'. How were dimensions determined: h� ��� Comments (on pumping r�commencfations,4nlet and outlet tee or baffle condition, structural integrity, liquid levels As related to outlet invert, evidence of leakage, etc.): Al GREASE TRAP. 41ocate 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.): 7 Page 8 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY,ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: er:aj'41) 1 �/yy I 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: 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:29&(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.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR,VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART C SYSTEM INFORMATION(continued) Property A dress: Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):(/(locate on site plan, excavation not required) If SAS not located explEin why: Typed l Teaching pits,number:_ leaching chambers, number: leaching galleries,number: leaching trenches, number, length: leaching fields,number, dimensions: overflow cesspool„number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil; condition of vegetation, ' a., ooa , A a CESSPOOLS;Lj� -(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 or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY:/,M7(locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note conditicn.of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I 9 Page 10 of I I OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property A 4dress: r 1-11 Owner: Date of Inspection: � U 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., O i U I _ L 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Property dress: Owner c \ Date of Inspection: r �c7 SITE EXAM Slope Surface water Check cellar Shallow wells t• ` - Estimated depth to ground water 3 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: ® IM210IL41 1541r 11 f Permit Number: Date:_ Completed by: �� HIGH GROUND-WATER LEVELCOMPUTAT)ON Site Location: I/ C.� `/ �/h_ Lot No. :Owner: / � �i1iJ/�—� - Address: Contractor: &,,&_—. l �y�; Address: rotes: STEP EP 1 Measure depth to water'table _ to nearest 1/10 ft. .................... . ..............................................:......:...: .Date month/day/Year i STEP 2 Using Water-Level Range Zone I and,hndex WeIVMap locate l site and determine: 1. A Appropriate index well I Ii OWater-revel range zone ......_.........................................:.... C S f EP 3 Using monthly report."Current Water Resources Conditions" determine current depth to l 'water level'•for index well .......:•:.. � month/year S T`P d Using .Table_ of Water-level Adjustrnen s j for index viell (STEP 2A), current depth to water le.rel for index.well ('STEP 3)., i 'and water-level'zone (STEP 2B) determine .eaLl ter-level adjustment•.......... `f P................................. 'STEP Lstimate depth to high water by subtracting the water- -level adjustment (STEP 4) from'measured'de'pth to water level at, site (STEP 1)'..................... .......................................................................................... l Figure 11--Reproducible conputat.ion Torn. I i TOWN OF BARNSTABLE V L( r" iv / ����£ to 4 SEWAGE # N' i,LAGE ASSESSOR'S MAP&LOT 6 0�O 'C1oP.S ,/ NAME&PHONE NO. 1' 1-A/L CO -e SEPTIC TANK CAPACITY 1A,S'fp rem LEACHING FACILITY: (type) (size) -,NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: C/61� E DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(1f any wetlands exist within 300 feet of leaching facility) Feet Furnished by I ve D r Its a Rm TOWN OF B , NSTABLE fAE-}+ RANQ'sjom ttS LOCATIaN - LO A- q \N A-!I SEWAGE # VILLAGE �kAQRDU S � 1 i ASSESSOR'S MAP & LOT 'INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WELL O PUBLIC WATER BUILDER OR OWNER ! I Nw, DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Ye No � � s l g 4 � �� � �� �� � .� � ,� ��� �� �� ''s s _ �^ ' ^ L l./11. i' �� _ ____ � 60 1 U-q-0 No..- �>�T l ... Fu$.-.....Z--.-......_........ THE COMMONWEALTH OF MASSACHUSETTS j^ BOAR OF HEALTH .�.1.... ..-..OF......- 6a44.4-�a4l!� ' Appliration for %pniial Works Tomitrurtion rrmft Application is hereby made for a P�er�m1it to Construct ( ) or Repair ( )-aann Individual Sewage Disposal System at: ls'- 0 LocLiddress 7 r Lot No. /q 13 . .... ���� J.V?t............ !!Ll�q.. .. -� , 1�ner Address .... ... .......................................... ..... ........ .............X......................................................... Installer Address U Type of Building •� Size Lot. j..�'°:�_._._Sq. feet Dwelling No. of Bedrooms______________�.1-_........................Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building I`o. of ersons_________________________ _ Showers a YP g ------------------------•--- P - - ( ) — Cafeteria ( ) Q' Other fixtures ............... ................. d -•-----------------------------------•------------------------------------- Design Flow__ _________________ ___ ___________ __gallons per person per day. Total daily flow.__..._____ �� gallons. W s�._.. WSeptic Tank Liquid capacity _gallons Length................ Width................ Diameter................ Depth............. x Disposal Trench—No_ ____________________ Width............... t ow al "�.__-_______ Total leaching area....................sq. ft. Seepage Pit No-----I.............. Diameter___ 4 inlet........j.P__....... Total leaching area.__,..3'��_ q. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by............................ ............................................. Date...................--------------------- Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ f-1-4 Test Pit No. 2................minutes per inch Depth of Test Pit..............._.... Depth to ground water........................ ' ..------- --_-•-- x Description of Soil....... tT� -_~_ --- V ---•--••--------------------------------------------------•-----•-•--------------------------------------_..----•------------------------.-------------------•----------...---------------...----------- W ------------------------------------------------------------------------------------------------------------------------------------------------------------------ -------------------- ................ U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ---•-•-------------------------------------------------•---------------------_..__........_._...---------------_.._..--•----------------------------------------------------------------._.........---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. / tG n x Signed 1! .---�...J / ----.--••--•1----- 5 �� Date Application Approved By_-/�j. _ -... F--{----------------------- D ate ?� Application Disapproved for the following reasons:..........................-------- ------------...-----------...--------------•--•--------- - -.....------ S: / Date PermitNo......................................................... Issued... - -- f Date No.. Fs$............................ _ " T4.1`E C6M'.90NWEALTH OF .MASSACHUSETTS BOARD OF HEALTH - _oF........ �c ,1 !.;{ �' ` ................ t Applir tibaa for 15hipus al 0rk,a ( onotrurtion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: 4 / ...... 4F� ,g r ..! + i4 i r_ .. Caw r E d l ':s..: d ` . Locario A dress r Lot No �/j kit. .. a 4W ��• Ow er .. Address +.7 ..... .. .................................... ..... r- __l4.. .t..... ..........._____.........__...___....._._.....__. i y n,taller Address _;Type of Building Size Lot__ __--: '" ___. q. feet Dwelling YNo. of Bedrooms.............. ._..----------•..........Expansion Attic ( ) Garbage Grinder ( } a`4 Other—Type T e of Building ____________________________ No. of ersons____._..________.__.____.._. Showers h Yp g p ( ) — Cafeteria Otherfixtures ................---.................................................................................................................................... WDesign Flow......_...............`_....................gallons per person per day. Total daily flow_-____-____ _` '_._..____........_gallons. WSeptic Tank L Liquid capacity/la allons Length................ Width_.............. Diameter---------------- Depth................ x Disposal Trench—No ____________________ Width �,*��a�l n tI f Total leachin area....................s ft. p (`r" a� 't gQ' Seepage Pit No._ ;.______. Diameter_ / �. e�li el�w inlet _______ _______-.Total leaching area___ T.47 '_ sq. ft. z Other Distribution boa ( ) Dosing tank aPercolation Test Results Performed l Y--:------•---------------------.........................----------------.,.Date....................................... Test lPit No. 1............_---njinutes per inch Depth of ,Test Pit.................... Depth to. ground water---..-..-_----_--_------ fJ, Test Pit No. 2................mnutes'per inch De Test Test Pit.................... Depth;to.ground water........................ .... O Description of Soil------ � �-�-------•-z �'--•�r�. -»'----�--- ' �-;;;'�• ---;-�--�"` ._ U UNature of Repairs or Alterations=Answer when applicable..................................................................................... . -••-------••---------•---------•-----------------•-•--•..._.._..-----•--•----'••._._.....__......------••--•-----•----.._..--------------•------•-••-------•------------------•--•--•••.._...:_.._--_... Agreement: The undersigned agrees to install the afore&-Bribed Individual Sewage Disposal System in accordance with ' the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the,board of Z .Signed...__ ._._:�.... . .. ---•-• - ••- --._..._..�---. .._.3 Application Approved BY y `l 'e°d .tt .° _ Date Z ,,;'Application Disapproved for the following reasons:............................ ......•---_--------_--_-_----_.•---- '.__ __ 8_..--- ..................................•.---.....------------•--•---------•------------------••--......---- •--•---•--•-•-•--.._..---•--••-----•-•-----••...._••---•------......-•--•-•-------•-•---••------- Date PermitNo......................................................... Issued..... _. . � �-�-fe ' Z-------------- THE COMMONWEALTH OF MASSACHUSETTS �� i✓ BOARD OF HEALTH ,y ' .• .gr .::............OF....... r -0.1T L .,� Tprtif it atr of Tampliattrp T IS TO CERTIFY 1hat the Individual Sewage Disposal System constructed ( r Repaired ( ) ...... fit. ............................... f ,...., at•. --w­ -'-. -__................}gar ;o'"-F'�-"Yv r- -_ tallet /d' - =- '�E -r ---- -----..... , has*been installed in accordance with the prov i ions of z rticle XI of The State Sanitary Code as described in.the Opplication-.for Disposal Works Construction Permit No-------------- ---------------- dated--- _ _,_ ._ 'THE,ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS UE® AS A G ARANTEE THAT THE, SYSTEM till FUN ION SATISFACTORY. �o �3 DATE.... ........................................ Inspector--41e.4 ....:.. ...!........: THE COMMONWEALTH OF MASSACHUSETTS BOARD OFF ,HEAL H• s . No.... •••... ....... FE ....... Permissiomig--hereby granted... _ ' _. ...._ ........... ............. to 1 onstru t 4 or Repa< ,( ) i Ind>vtdtz 1 Sew e Disposal S tem ,� Street as shown on the application for Disposal Wori:s ConstriKtion Pep it No..� . . . Dated-_ Byard of Ilcaltlt' DATE =..... • ----:-- FOP.M 1.255,.HOBes & WARREN, INC.. RUftLlSHEPS r