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Home My WebLink About0141 CEDAR TREE NECK ROAD - Health 141 CEDAR TREE` NECK ' R-- A= V ILA TOWN OF BARNSTABLE yM �ntatC�as, LOCATION Iy Celdar Ne'r� /-d SEWAGE # TILLAGE - M, C ASSESSOR'S MAP & LOT o INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY i LEACHING FACILITY: (type) �Jf% ,r (size) NO.OF BEDROOMS-/2 BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by p 1 ►x 2�1 a3 2g 36 NI - P4:#2- U I•. o f t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 141 Cedar Tree Neck Rd. Property Address Patricia Manuel Owner Owner's Name information is required for every Marstons Mills MA 02648 4-30-13 page. Citylrown 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 on the ��q►►unu►p/�� use only OF he tab ```mputer, �� ,SH Mg ss9c% use the return 1. Inspector: �.; yG key to move your l � cursor-do not James D.Sears lJJ JAMES ,m az Name of Inspector =c�: :CO= key. Capewide Enterprises,LLC �'. o o "� Company Name �' T?f 153 Commercial Street ��/��Sf I N Spt�G�\````\ Company Address Mashpee MA 02649 Cityrrown State Zip Code 508-477-8877 S 1623 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 iW ction. Tire inspe4tion was performed based on my training and experience in the proper function and (r 1i itenance pf on e sewage disposal systems. I am a DEP approved system inspector pursuant tokSection 13 340 Title 5(310 CMR 15.000). The system: y+1( o — ® Passes ❑ Conditionally Passes ❑ Falb ❑ Needs Further Evaluation by the Local Approving Authority 4 „� rn 5-1-13 It'dpectors 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 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•3/13 Title 5 official Inspection ForISuTSewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 141 Cedar Tree Neck Rd Property Address Patricia Manuel Owner Owner's Name information is required for every Marstons Mills MA 02648 4-30-13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cost.) 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: ❑ 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-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17 f Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 141 Cedar Tree Neck Rd. Property Address Patricia Manuel Owner Owner's Name information is required for every Marstons Mills MA 02648 4-30-13 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 (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 141 Cedar Tree Neck Rd. Property Address Patricia Manuel Owner Owner's Name information is required for every Marstons Mills MA 02648 4-30-13 page. Cityfrown 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 El ® Liquid depth in I is less than 6" below invert or available volume is less than Y2 day flow 4 FA ch/iry G t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 I� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM °� 141 Cedar Tree Neck Rd. Property Address Patricia Manuel Owner Owner's Name information is required for every Marstons Mills MA 02648 4-30-13 page. Cityrrown 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 es to an question in Section E the system is considered a significant n h y y y q y ca t threat, 9 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 141 Cedar Tree Neck Rd. Property Address Patricia Manuel Owner Owner's Name information is required for every Marstons Mills MA 02648 4-30-13 page. CitylTown 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 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)] D. System Information Residential Flow Conditions: Number of bedrooms(design): NA Number of bedrooms(actual): 6 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 660 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 141 Cedar Tree Neck Rd. Property Address Patricia Manuel Owner Owner's Name information is required for every Marstons Mills MA 02648 4-30-13 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Note: Two systems. Right side system has two pits. Left side, system 1500 Gal tank and pit. Number of current residents: 0 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 NA 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NADate 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 141 Cedar Tree Neck Rd. Property Address Patricia Manuel Owner Owner's Name information is required for every Marstons Mills MA 02648 4-30-13 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: 07/11 Was system pumped as part of the inspection? ❑ Yes 0 No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, ? soil absorption system T 5�2>£ S ySTf/✓I ❑ 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): Right Side System Two Pits t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 8 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 141 Cedar Tree Neck Rd. Property Address Patricia Manuel Owner Owner's Name information is required for every Marstons Mills MA 02648 4-30-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: NA Were sewage odors detected when arriving at the site? ❑ Yes ®. No Building Sewer(locate on site plan): Depth below grade: Left 4' Right 9' 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.): Left side 4" PVC SCH 40 Right Side orange bur a and PVC SCH -40 Septic Tank(locate on site plan): -•L E�T S/J S S S-15 7T/4 3' 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 Sludge depth: 1" t5ins-3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 141 Cedar Tree Neck Rd. Property Address Patricia Manuel Owner Owner's Name information is required for every Marstons Mills MA 02648 4-30-13 page. Citylrown 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 29" Scum thickness 1" 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 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 at Tbelow grade w/cover's at 8". in and outlet baffle'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 I!ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 141 Cedar Tree Neck Rd'. Property Address Patricia Manuel Owner Owner's Name information is required for every Marstons Mills MA 02648 4-30-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 t51ns-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 141 Cedar Tree Neck Rd. Property Address Patricia Manuel Owner Owner's Name information is required for every Marstons Mills MA 02648 4-30-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ 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: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 141 Cedar Tree Neck Rd. ' Property Address Patricia Manuel Owner Owner's Name information is Marstons Mills MA 02648 4-30-13 required for every !i page. CityRown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 3 El 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.): (Left side) One 1000 Gal. Precast Pit. Pit at 46" below grade w/steel cover at grade in driveway. Pit is dry. No sign of over loading or high stain line. (Right Side)-one 1000 Gal. Precast pit. Pit at 80" below grade, w/steel cover at grade in drive way. Pit is dry. No sign of over loading or high stain line. (,cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration T S/D 1 Depth—top of liquid to inlet invert Dry Depth of solids layer Depth of scum layer Dimensions of cesspool 1000 Gal. Materials of construction Precast Indication of groundwater inflow ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 f • Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 'r 141 Cedar Tree Neck Rd. Property Address Patricia Manuel Owner Owner's Name -information is required for every Marstons Mills MA 02648 4-30-13 page. Cityrrown 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.): Main is one 1000 Gal. Precast Pit. Pit at 95" below grade w/cover at 13". No inlet tee , outlet tee. No sign of over loading. 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.): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 141 Cedar Tree Neck Rd. Property Address Patricia Manuel Owner Owner's Name information is required for every Marstons Mills MA 02648 4-30-13 page. City/Town 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 7- 6 Rd 5, 0 0 w� Y t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 141 Cedar Tree Neck Rd. Property Address Patricia Manuel Owner Owner's Name information is required for every Marstons Mills MA 02648 4-30-13 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Np Estimated depth to high ground water: 2 fe eett Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: Past report 12-27-99 US GIS G.W. Map's ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: G.W.off Past Report 12-27-99 Bottom of Deepest Pit 13'-6" T-6" above depth of past report. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 141 Cedar Tree Neck Rd. Property Address Patricia Manuel Owner Owner's Name information is required for every Marstons Mills MA 02648 4-30-13 page. Citylrown 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 t5ins•3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Ole �?000 BORTOLO T TI CONSTRUCTION, INC. ; .� 45 INDUSTRY ROAD, MARSTONS MILLS, MA 02648 4 508-771-9399 508-428-8926 FAX: 508-428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address:wil, Date Of Inspection_ Iuspec or's Name: ner's Name and Address Q gip. &( g,;�2A 605-- CERTIFICATION STATEMENT: I Certify that I have personally Inspected the Sewage Disposal System at this address and that the informa- tion reported below is true,accurate and complete as of the time of Inspection. The Inspection was perform- ed based on my Training and Experience in the Proper Function and Maintenance of On-Site Sewage Dis- posal Systems.T system: Passes Conditiona asse Needs F r Eva i By the Local Approving Authority Failur Inspector's Signature Date: The System Inspector shall submit a copy of this Inspection Report to the Approving Authority with 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. INSPECTIUMMARY: T4 PA A) SYSSSES: I have not found any Information which indicates that the System violates any of the fail- ure criteria as defined in 310 CMR 15.303. Any Failure Criteria not evaluated are indi- cated below. B) SYSTEM CONDITIONALLY PASSES: One or more System Components need to be Replaced or Repaired. The System,upon completion of the Replacement or Repair,Passes Inspection. Indicate yes,nor,or not determined(Y,N,OR ND). Describe bases of determination in all instances. If"not determined",explain why not. The Septic Tank is Metal,Cracked,Structurally Unsound,shows Substantial Infiltration or exfil- tration,or Tank Failure is imminent. The System will Pass Inspection if Existing Septic Tank is Replaced with a conforming Septic Tank as Approved by the Board Of Health. Sewage Backup or Breakout or High Static Water Level observed in the Distribution Box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven Distribution Box. The System will pass Inspection if(With Approval of the Board Of Health): - 1 - W 1 SUBSURFACE'SE AGE -D SPOSAG SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Broken pipe(s)replaced Obstruction is removed Distribution Box is leveled or 'replaced The System required pumping more than four times a year due to broken or obstructed pipe(s). The System will pass inspection if(with approval of The Board Of Health): x -Broken pipe(s)are.replaced- Obstruction is removed. 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 HELATH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or Privy is within 50 Feet of a Surface Water Cesspool or Privy is within 50 Feet of a bordering Vegetated Wetland or a Salt Marsh. 2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES THATTHE SYSAM.IS_FUNCTION- INGIN.A MANNER THAT-PROTECTS THE:PUBLIC:HEALTH AND SAFETY AND THE ENVIRONMENT•, The system has a:Septic Tank,and Soil Absorption System and is wcthcn'100 Feet to a Surface Water Supply or Tributary_to.a Surface Water Supply..., The System has a Septic Tank and Soil Absorption System and is with a Zone 1 of a Public Water Supply-Well. The System has a Septic Tank and Soil Absorption System and is within 50 Feet of a Private Water Supply Well. The System has a Septic Tank and Soil Absorption System and is less than 100 Feet but 50 Feet or more from a Private Water Supply Well,unless a Well Water Analysis for coliform bacteria and volatile organic compounds indicates that the Well is from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D)SYSTEM FAILS: I have determined that the System violates one or more of the following Failure Criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overload 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. r N {.: w Static liquid level inahe dis,tribution.box.above outlet invert clue to,anoverloaded or clog- i: gWISAS,or cesspool.,, t r • A ,. N, Liquid;depth in cesspool is Iess than-G „below invert or available volume csless than 1/2 ,.. ; day flow. Required pumping more than 4 times in the last year NOT due"to clogged or obstructed pipe(s). Number of times,pumped - 2 - SUBSURFACE SEWAGE. DISPOSAL,SYSTEM INSPECTION; FORM PART A CERTIFICATION (continued) 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 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 ggd 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 The syste m►s With►n 400 Feet of a surface drink►ng water supply ` The system"i's'withni'200 Feet_of a tributary'to a surface d''r nk►ng water supply. The system is located in a nitrogen sensitive area Interim Wellhead Protection Area ` (1WPA)or a'mapped Zo►ie ll'of a public water supply well The owner or operator of any such system shall bring the'system and facility into full compliance with the groundwater treatment program requirements of 315 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the fallowing have been,done: ,/Pumping information was requested of the owner,occupant,and Board of Health. _None of the system components have been pumped for atleast two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As-built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. '> system components,excluding the Soil Absorption System,have been located on site. 3 The septic tank manholes were uncovered,opened,and the interioriofahe septic tank was in- spected'for condition of baffles or tees,•material of construction,Aim ensions,,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 or approximated by non-intrusive methods. - 3 - ", SUBSURFACE SEWAGE"DISPOSAL SYSTEM' INSPECTION FORM PART B CHECKLIST(continued) _JZThe facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C r �, r,:.. .. ram•. ,. ._., SYSTEM' INFORMATION i FLOW CONDITIONS RESIDENTIAL: Design Flow:_y VO gallons Number of Bedrooms:__Nynper of Current Residents:62 Garbage Grinder:_ X) Laundry Connected To System: Seasonal Use:�,q Water Meter Readings,i vailable: V Last Date of Occupanc COMMERCIAL/INDUSTRIAL:/00 Type Of 9; , 6lis"ent . n - . . . .jfDesign Flow: --gallons/day-..Grre'?azsee Tr-apPr esenC:' (yesor Industrial Waste.Holding.TankPresent: . _ Non-Sanitary Waste Discharged.To.The Title V System:... Water Meter Readings,If Available:, Last Date of Occupancy:. OTHER: (Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING-RECORDS any-source of-information:41 ,(�,r� 7 System Pumped as part of inspectionx-A&- If yes',volume pumped: gallons Reason for Pumping: TYPE OF SYSTEM: Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If veL attach previous insp ction records,if any)._ .._ —26ther(expl 'n�: J ' . PROXIMATE AGE of'all components,date-installed(if.-known)-and source of 1nformatto'n � �1 Sewage odors diffiected when-arriving at the site - -- __. ..._._.... -4- SUBSURFACE SEWAGE',DISI'QSAL,S.YS'FEM•'.INSPECTION FORM PART C / GENERAL INFORMATION (continued) SEPTIC TANK: ✓ i\(� $ / � � Depth below grade: Material of Construction: t .�concrete metal FRP Other (explain) Dimensions: •6" Sludge Depth: Scum Thickness: O Distance from top of sludge to bottom of outlet tee or baffle: f y Distance from bottom of scum to bottom of outlet tee or baffle: 1Q i9' Comments: (recommendation for pumping,conditioin of inlet and outlet tees or baffles,depth of li uid level in relation to outlet invert,structural integrity,evidence of akage,etc&a,;g a4 1000 . GREASE TRAP: IL)v Depth Below Grade: Material of Construction: concrete metal FRP Other (explain): Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle: { Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles;depth of hquirlg'level outlet invert,structural integrity,evidence of;leakage,etc �n relation to _ _.. __....._ TIGHT OR HOLDING TANK:w Depth Below Grade: Material of Construction: concrete metal FRP Other (explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm Level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: 1-90 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: P Pump is in working.,order r Comments: (note condition of pump chamber,condition of "inps and appurtenances,etc.) - 5 - aSUBSURFACE;SEWAGE`DISPOSAL'SYS'FEM"IN'SPECTION ,'FORM PAIIT C SYSTEM INFORMATION(continued) SOIL ABSORPTION SYSTEM(SAS): (Locate on site plan,if possible; excavation not required,but may be approximately by non-intrusive methods) If not determined to be present;explain: Type: Leaching pits,number: , -3LLeaching chambers,number: Leaching galleries,number: Leacahing trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number: omments,(not conidtion of soil,signs of hydraulic failure le 1 of pondinjg,coiAition o vegetation,etc.) ., CESSPOOLS., FY Number and configuration: ; ' Depth-top of liquid to inlet invert: y Depth of solids layer: Depth of scum layer: Dimensions of Cesspool: a ! R Materials of construction: Indication of groundwater: Inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) PRIVY:_ Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil,signs of hyddraulic failure,level of ponding,condition of vegetation, etc.) T .4 •..i . .. T. ��t i. �.: t'...Sa 3p _t3 � •i i �... F 3`1 YJf ! �.S.r s �1. �' i ...M� _.•.. t k i - 6 - r SUBSURFACE 'SEWAGE DISPOSAL'.:'SYS7'EM INSPEC'FION'=FORM I'ART C SYSTEM INFORMATION(continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references,landmarks or benchmarks. Locate all wells within 100 Feet. 1 � , 9 4? 16 la 1 .. r =4p1 _ .:i _�'_..........,— ._,.� e •.;' ...... -;�:e wkelfi.. - _ �j tz i. t„�i�x�i,'f Ek�f_;3'..� .._....�,.__ i✓ s i t; ,} 3 Al _.... _..tea....'..,. _._.....__.......... _.__.._..... _ } `l 1:, .Y l:. 8..,.,_• DEPTH TO GROUNDWATER: J Depth to groundwater: 2-1 Feet Method of Determi lion or Approximation: �Xi" 1�t? / 6 u f0aldl 7 _ BORTOLOTTI CONSTRUCTION, INC. 45 INDUSTRY ROAD,MARSTONS MILLS, MA 02648 508-771-9399 508-428-8926 FAX: 508-428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: N ' Date Of Inspection 9 Inspector s ame: ner's Name and Address #Jp. CERTIFICATION STATEMENT: 1 Certify that 1 have personally Inspected the Sewage Disposal System at this address and that the informa- tion reported below is true,accurate and complete as of the time of Inspection. The Inspection was perform- ed based on my Training and Experience in the Proper Function and Maintenance of On-Site Sewage Dis- posal Systems.TIfsystem: ✓ Passes , Conditiona asse Needs F r Eva i By the Local Approving Authority Failur Inspector's Signature' Date: �• �1� The System Inspector shall submit a copy of this Inspection Report to the Approving Authority with 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. INSPECTIQN SUMMARY: A) SYST PASSES: I have not found any Information which indicates that the System violates any of the fail- ure criteria as defined in 310 CMR 15.303. Any Failure Criteria not evaluated are indi- cated below. B) SYSTEM CONDITIONALLY PASSES: One or more System Components need to be Replaced or Repaired. The System,upon completion of the Replacement or Repair,Passes Inspection. Indicate yes,nor,or not determined(Y;N,OR ND). Describe.bases of determination in all instances. If"not determined",explain why not. . . _ The Septic Tank is Metal,Cracked,Structurally Unsound,shows Substantial Infiltration or exfil- tration,o'r Tank Failure is imminent. The System will Pass Inspection if Existing Septic Tank is Replaced with a`conforming Septic Tank as,Approved by the Board Of Health. Sewage Backup or.Breakout or High Static Water Level observed in the Distribution Box is clue 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): -1 - r '- SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FORM PART B CHECKl.1ST(continued) _jzThe facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIAL: Design Flow:�40&&_gallons Number of Bedrooms:_N er of Current Residents:0/2 Garbage Grinder: Laundry Connected To System:_=_ Seasonal Use: Water Meter Readings,i vailable: Last Date of Occupanc COMMERCIAL/INDUSTRIAL:/0Q Type of Establishment: Design Flow: gallons/day Grease Trap Present:,(yes or no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,if Available: Last Date of Occupancy: OTHER: (Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS any source of information: ��6�Y�i ��r.r! System Pumped as part of inspection - If yes,volume pumped: gallons Reason for Pumping: TYPE OF SYSTEM: Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy SI ared System(If ye attach previous insp ction records,if any) her(expl 'nl: �) PROXIMATE AGE of all components,date installed(if known)and source of information: ZL Sewage odors d ected when arriving at the site(/ -4- f JAN-18-02 02 : 16 PM BARRY. MAF4UEL 6174845889 P 02 OLT-24-2201 C9:08 -'OT70N RERL EE"ATE" $08 4Z@ SS46 F'.UZ- OB C. I;ORTOLOTTI CONSTRUCTION, INC. 45 INDUSTRY ROAD,MARSTON$ MILLS,RSA 02648 5GO-771.9399 $08-428.8926 FAX: 50"28-9399 SUBSURFACE SE WAO,9 DLSP®SAL SYSTEM flKSPtEC'norl Ii°ORN1! PART A CE R.TIMCA IO1r Ptdperiy Addrem. Date Of tpspectlon Ilia PC ner's�tatnq and Atddrtrsa '; �'' aL6TA7CT�dE1Y�, i Certlry that 11t8vt paraar(Tally Inepecled the Sewage Disposal System at thie address and that the talforrns• 03n reported beivw is tree,aeclrrate and complete as of the time of Impectlen. The Inspecdon tree portbrm. ed based on my Training and 9spartrenee!tt the proper ltuntcties and 1,4sinteittulce of aOtrSitt:Saewage Oia. posal8ystems.l systein" �._K_„o passes ._.. condlltona alas Needs F r Eva By the local Approvisig Atuthorlty eFallu inapeetor'sSlgnaturs /_ te* jam' ... The System blrpector shall subralt a copy of this Inspection Ropvrt to the Approving Authority with Tl+ircy (30)Days or oompietin`rhea,trsspectlott, It the 3ydeen fa a Shared System ar has®!?�i3tt r'i®iv a6 20,b00 gpd ar Greater,the leospeetor and ehe 5yatenr O ,ner shall rubmlt the Report to the appropriser Ragiortal Office of the Dapartneent Of1Aalrbiatrterttal protection. The Original slould he lent to the,Systern Owner and ceples sent to the Xm*,D(applleable and tiro Approving Autita►rity. � A1L� A) SYS PASSES: I have not found asry information evallch Indicates that the System violate$Rap of the fail- ure criteria as defined In 310 CM R 13J®3. Any Failure Criteria not evaluated are indt- cAted below. 2) SyS'T'EM COND171 NALLY PASSES., One or moan System Componesig aced to be Replaced or Repaired. The System,upon ` coq;tplettun of tlae ROOlactleaeelt ar Repair,passes inspection. indicate yea,nor,Qr not determlaeed()l,N,OR ND). Dcledbs bales of deterttd®ation in sit lastjocas. it"ant determined",expkin why Apt. �The Septic Tank is Metal,Cracked,Structurally UnsOUA4.shoves Substantial Iartlttrad On or axflt- tradon.or Tank 1'Talluct Is in'ttaiaont. The System will paea Inspocdtuea It jxlstlatg Septic Tank is Replaced with it eonfoeming Septic"Tank as Appa+svtad by the l card of tdealth, ®8eevaga Backups or>grtakout or High Static Witter Lvyel observed in than Distribution Bolt is due to broken or obatru sd pipe(a)or duct to 4 broken,settled or uneven 01stributiam Bea. The Syatam Will pass I'Atipection it(WRh Approval of the Board Of Health); .(- J N-1:3-02 02 : 1 PM BARRY. MANUEL 6174845889 P. H5 C0770N REAL EiTATE 508 420 ?946 P.0511W SUSSL'It.FACE SEWAG$ D13POSAL SY9'IEN INSPECTION N FORM PART 0 CRECUIST(eont(nsted) _ZT11a facility o'wAsr(Arid otCupaa(T.1f different Iran:6WA00 wAra prodl:led with Informarign on tits VOW rnaintsnsnee a(Subsurface Ilteposal System. SUBSURFACE SEWAGE DtSPUSAL SYSTEM INSpZCTION (FORM PRAT C SYSTEM, 14NORHATION FLOW CONDITIONS Design Flow: gallons tYwmbsr of BedroorgD; N er of Current Rwidemts: GKrbage Grinder: Laundry Connected To System: 5easoe+ai Use: Wutcr Metar Readings,l allable: V , Lcse Date of or.eupanc S�1I*t�'IY?.IIt�TBIBL.:%Z7Q • Type of Establishment, Dtat9np10w:____9ellonVd%y Grease TrapProsenit (yes or no) Indush'1a1 lWas,e Holding Tank Preae„t: NonSanitary Waste Dlschurged To The Ti11c vSystem. WA[ar Meter Readlnp.If AvaDable: Lase Oats of Occupancy- OTHER. (Ds3cr1be) Las[bare oroecupaslcy: - C&NERAL INFORMATION PVMPING RECORDS any source of 1,lftlrlflotivae: zg System Pumpedas part of onspeetio:�, . Uye9.volume punpedr yn[tans Reason rot Pumping: T`Y?E OF MIX% Septic TonWDIstributlon RoviSoil Absorption Syslom _841gle C$Aipgoi _,_,_ Overflow Cesspool _,, Privy 31larosl System(If a Attach previous las tign records,If any �f,t,ea(etpl �tg�._ -� P R® AUS of a?I cQ mponcn,s,date InstalWd(I(known)and suurce of Informattoa: _ SaW494 odors d clod when arriving at the site_ez Q:: JAN-18-02 02 : 19 PM BARR` . raANUEL 6174845889 P. 06 �•T`��-r�l?1 �Ei �3 COTTON REAL HFATE SCE 420 894E P.00-B8 SM%URFACE SEWAGE DISPOSAL gYSTIM 04SPECTION FORM PART C GENERAt114FORMpATION (continued) 814 P'C!C TO K: Depth betuµ•greater A+laterls!oY C'orulrtactd9nt�eoaacrote� rraetal�,b'RP��Ottua• (oxpt9ln}� - Atrnensiot;etDeptu.,�ye0 9cuau Thiele ome t) Distanee from top o sludge to bottom or 9udet its or baxfi®r -" Distance from bottom of scares to bottom of outltt toe or Was,�_Aw` Comments. (recernmendatlon for pumping,condittoin otinlo4 and out taws or baldlert,dapiiy of 11:uid level in relatJen Rv 9 filet irovatry etruclu $t Integrity,evidence or Akags,stc.�� / a e . l . 1 GJUASE TRAP: Depth Below Grade; Material of Coaastruction: eoiacrete reaetal (eXlalalaJt �,.,,_._,F'R1P Other IDl;rten4lons: Seurn Tbtc,knesst DIstanes from top ofocum to toy ofoutlet lee or baffle: Casements:4rec0mMendadon for pumping,copoltion of inlet geld outlet teat or bsftlet4 de®tb of liquid level In relitt(On to outlet Invert.structural ltttcgrltyr evidence of leakage,etc.) I':CUT OR110i piiriG TAq-4Kj_4X (expla n): Grade:material of Construoti9ua�„��aacavte _meta!:*kdl r_. _t)titer {e7tplain): Otaea;;alons:_ Capacity; alfona Dees FlT ow: Alarm Leeel:_ """'^ �^^-g it �allonsfdaay Comments;(condition of tni;st tee,corWrion of alarrn and Reatswitctacs,eta.) 17L8TR3BtJ'd'3(JlV 1�Q76w-�6 Depth of 116nld level Above Outlet tnvort: 0mrntnts:(note if level and distribution-is equal,evidence of soft carryover,svidadae of leakage into�;r out of bux,etc.) Rump is in worklog corder. Coruments! (note Condition of puanp chamber.condition orpun;ps and appurtertaaaes.etc.) :: 02 : 19 PPI F.ARRY. PU4NUE;_ 617484.5889 P. 137 es:zq C(31Tpri REAL E5TATE See 4je 9946 P.0-108 SUB3UPJACE SEWACE DISPOSAL SYSTEM INSPECTION FOKM PART C SYSTEM UNFOftMMAT1.014(cuntlnued) "QIL ALSOEt TION SYSTEM(SAS), ` (Locate on site Plata,If possible;exsara4vn not requfrwd,but may be approximately by acn•latrualve methods) If not dotarnVned to be present,tsplain; Type; LeaehinE pits,number: t.wachini;chambpre,mAmber'—Leathing Vel.lnrtcs,numbers Lenanhlnj trenches,ovinbor,lemgth: — Leaching fyefads.number,41mension� Overnow cesspool,number; --- omments:(no condddon of solY,suns of hydraulic failure le I of.pond{t�,con ltiv a veSetatlott,et,-)7 , _ A A e it t css5P�tDLS . t oy • ¢ f Numb r®nd oontlzeratlon.---Dapth•tep of llgold to Intel invert; Dipth orsollds layer: Depth ormum layar., Dimensions of Cesspool,, _�...v Materials oteonstrttetlon;_ IaJicakbn ot't�ragnelwat�: Inflow(cesspool russet be pumped as part of lmspsotlon) ®r.arnan'$Y(note contiiti4) ofsatl,ei$n6 of hydrauclic failure,level orponding,catudltlon of wetatation, Matertais of construction; DImellsions, Depth or 9olkh: .,.....,,.:,•m..�__---- Comm.,"ts:(note comaltioa of soil,suns of byddroulit failure,level 91pounding,rsndidon of vegletutkon etca`s � e JAN-1:.--b2 02 : 17 PM BARR`i'. MANUEL 6174845889 P. 03 CQTTutV RERL ESTATE 5fi79 4"c.0 85�6 p.1� E�6 • r SUBSURFACE SP-WAGE DISPOSAL SYSTEM INSPECTION RAM PART A CUTIpICATION (continued) .Broken pipes)repiated �Obatruef om is reMuvad Dlsirlbudon Box is leveled or replaced The System raquirod putn:piaa more than four tastes 4 rent°dine to broken or obstructed PIMS). The system will PRIS tneptsdion If(With opprovpl of The B68rd Of Health); Broken pipe(p)are repioeed Obstruction id removed, Q FURTi1lER EVALUATION 13 RSQUIUD BY TIM 80AR11 or 111CALTHi 01yS,_,Condition$oxlSt Which require rurilhr.r evaluation by the Board Of(health IT,order to determine It the System is calling to protect the Public Fkaliit,Safety and the Environment, 1)SYSTEM WILL PASS t1NLE5S.BOARD OF 11111LATH DKTERANLs''KAT THE SYSTEM 13 NOT FUNCTIONING IN A MANNER WHICH WML P.ROUCT'T'HE PUBLIC XNA LTH AND SALTY AM Tn zNvjRONrZ yT! esspool or privy Is within 60 Feet of a Sbrftrco avatar Cempool er Privy Is wllhtn 50 Feet Of A bordering Vegetated Welland or a SAIL r4arstt, 1)M TJICX WILL FAM UN US 77JM SOARD OF MIAL,TH tAgVp 8[.1Dj.U^.EVATER S Up'?JLIER'IP' 'B" RO"'ATdS)DVM&NIINU TITAT TILE SYSTZM IS RUNCTION• iNG IN A NIMNER THAT PROTECTS THK MOL1C HEALTU ANIID SAFETY AND'TH>L ' ENVIKOMMI>i NTt .The system has a Septic'Tank And Soil Absorption Systertt and IN within 100(toot to a SurGce caster Supply or Tributary 10 A Sutfacq Water Supply, The SyStse:r has a Septic Task and Soil Absorption System and le With a Zone I of a publls Water Supply Wolf. he Systein has a Septle Tank And Soli Absorptio Water Supply Well. n System and i1 within 30 Feet or$private The System has a Septic Tank and Soil Absorption Systeltt and is Ies1 than to Feet but SO Feet or more thorn a PFJvzty Water Supply Well,unless a Wad Water Analysis for oailcorm baet"15 aril!volatile orgaalc clumpounds indleates that the Well 11 rr®rt pollmdon[rant the((dilly and th#presence of ammonia n(t.-alien and eltrzte tiltrogen is tgdal to or less then S ppnL I�)Sys rEM FAMS: ,a„,„„r have dcOrntlued that the System violates one at more of the following Failure Criterla as dellaed In 3t0 CMA 13,303. The basis for this determination is ldentifled below. The Board 4f McAith should be Contacted to determine what Will be necessary to oorreot the fellure. Backup of sewage Into facility or system componeut clue to 00 overload or clogged SAS or aasspool. .Dlscldar;e or posditng or ernuo ut to tit&sumacs Of the ground or smr4pcs water&due to an overloaded or alaC9gd SAS or cesspool. �Static liquid tevul in IN@ distribultore box above outlet invert anus to ant overloaded or clog. gel!SAS or cesspool. Liquid depth la eesepoal Is teas than V below invert or Avollable volume is Ieae than Ill day(low. —Required puenping more than Sl times In tilt lost year ZDX due to eloggid yr obstructed plpe(s). Number of timas pumpers , . Z . JOH-18-02 02 : 18 PM BARRY. MANUEL 6174845889 P. 04 OCT-2•1-2001 ES-08 M-1711 PETAL ESTATE 5D8 4M 8946 F lel 4..Vib r . 31MURE+ACE SEWAGE DIUOSAL SYSTEM INSPECTION 00R.'11 PART A CERTIFICATION(continued) Any portion of the Soil Absorptlan System,caespooi or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within loll Feet of a sut-i'ace water supply or trlbutara,to a surface wetter supply, Any portion of a cesspool or privy is within a Zone I of a Public Wall. y portion of a eesepool or prieY is within g0 Feet of a private water supply well. Any portion*(a cesspool or privy in,Io s than 100 Feet but greater than 50 Feet front a prlveie water supply well with no acoeptable water quality aaelysis. tr the well has boon aoaiyzvd to be acceptable,attach copy of Well water analysts for coliform bacteria.rolatik organic oornpourtda,erelmonia nitro=en and nitrate nitrogen. E) LARCA SYSTEM]FAILSi The following criteria apply to a large System In additloit to the ariterla above, . The,design 110,11 of a sytteas Is 10,000 gad or greater(Large System)and the syekna It a sigstiflcant threat to public health and solely lied the environment because one or more of the following cvndidons oeistt The system is within 400 Fact of a surface drinldng water supply he system is within 200 Feet of a triWary to a sorfstce drinking water supply The system IS located In o tsltrogon Sensitive area Interim Wellhead Protection Area (JWPA)or a mapped Zone it of a public water supply hall. The owner or operator or any such System shall bring the system and facility into full cotapliance Willi the groundwater treatment pregr4sh requirements e0119 C R 5,00 and 6.00. Please consult the local regional office of the Departmeur for fUrther information, SU69URFACE SEWAGE VISPQ$f1 L SySWEM INSPEC'ITDN FORM PART H CHECKLIST Check it the following have been dotter. Pumping Infcrntatlon was requested of tilt owner,occupant,and Board of$ealth, _�- 'ona of the system compnaonts have been pumped for at,lcast two weeks stud the system itns been receiving n®rrhal flow rates during that period. Large votumes of water have:asst been introduced late the system recently or as part of this inspection, ✓ As-built plans have been obtained and exomined, Nate if they are set livailable with NIA. The facility or dwelling etas inspected for signs of sewage back-up. se The system does not reoelve aeon-ea�aitary ar industrial waste flaw. -,-The site was InspettP4 fqr sighs of breakout. All system components,extiuding the Soil ANorptlon System,have been located on'slte, TIIe septic tank snanitoles were Vilevverett,opened,Ind the Interior of the septic tank was in. Nested for condidon eP bsffies or toes,material of construction,diviensiam,deptit of liquid. �� depth of sludge,depth of itum. The size and location of the Soil Absorption System on the site has been deterlulned based an existing Information or approximated by non-Intrusive methods. JAN-- 18-02 02 .20 PM BARRY. MANUEL 6174845o89 P. 08 CC'-24-2001 MOM COTTOI•a REAL ESTATE 5Va 420 6946 P.O9.'0s, SUBSLIWACE UWAGE DISPOSAL SYSTEM INSUCTION FOPM DART C SYSTEM INFORMATION(continued) SKETCH OF SEWAG$ DISPOSAL SYS°t°>& 1, include tlm to atloast two permanent r1rareacm,140dan4rks er beuchtnarlur. Locate all welb within 100 T'cet, 1,310 all L DEPTH TO GROUNDW I Depth to grovA0Wotsr:--- /� Mathod of Daterml tlon or Appmidtrlagons / v�`/A �t �J�` . 7 . 9 TOTAL P.00