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HomeMy WebLinkAbout0346 OLD MILL ROAD - Health 3460IdMill Road �MarstonsMills; P : �1 = 1)461 080 0 TOWN OF BARNSTABLE LOCATIONC%3 Y6 % a ZL& adZ SEWAGE # VILLAGE XkU0,6a a ASSESS R'S MAP & LOT 61 090 lV SPr;/7>2S NAME&PHONE N - SEPTIC TANK CAPACITY .JDC .LEACHING FACILITY: (type) 4�� — (size) NO. OF BEDROO S 1 B'`ILDER Oq OWNE 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 �/ lD : I ba) c�I1�n kjcic �'` .TOWN OF E TABLE LOCATION c 6� �J SEWAGE # /� r f� VILLAGE �S [h) i�C ASSESSOR'S MAP & LO7P—*bC1�INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) (Y NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 6``� p`c� IOU A CD pA jti f. e • , _1 L6CATION s S SEWAGE PERMIT NO. Y n2- ✓, „P INSTALLER'S NAME & ADDRESS 0 UIIDE R OR OWNER S �� r ► A r 5z DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED y .. V r '`, r `e ~ i -3 n � M � _ �---- 1 ��/. �. a�fG� Deb Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal Systern Form-Not for Voluntary Assessments ca 346 Old Mill Rd.Marton Mills, MA 02648 Property Address v Edward Connolly ref owner's Name inf�n is asset- M MA 02025 10/1812016required for every " page t*f own slams zip c«re came of Ir 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. 'm��tom A. General information �� �� q�(10 on the computer, use only the tab 1. Inspector key to move your cursor-do not Paul Martin use the return Name of Inspector key- Cape Cod Septic Services - v t� Company Name 350 Main St Company Address W.Yarmouth MA 02673 Cityrrown State Zip Code 508-775-2825 S15016 Telephone Nwdw t.icwse Number B. Certification I certify that I have personalty 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 perfomled 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 16.000).The system: ® Pam ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 4� 10/21/2016 rnspwWs 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. ff 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 time system will perform in the future under the same or different conditions of use. t5uu,3ns Title 5 Olr�aal kWechm Form Sularraoe SewaP Disposal Syshun•Pap 1 or 17 SUS . r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 346 Old Mild Rd. Marstons Mills, MA 02648 Property Address Edward Connolly Owner Owner's Name information is Cohasset MA 02025 10/18/2016 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System in working condition B) System Conditionally Pass es: ❑ 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 Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 346 Old Mill Rd. Marstons Mills, MA 02648 Property Address Edward Connolly Owner Owner's Name information is Cohasset MA 02025 10/18/2016 requi-ed for every page. Cityrrown 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•3/13 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 , 346 Old Mill Rd. Marstons Mills, MA 02648 Property Address Edward Connolly Owner Owners Name information is required for every Cohasset MA 02025 10/18/2016 page. CitylTown 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 El ® 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 'h day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 i i i i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 346 Old Mill Rd. Marstons Mills, MA 02648 Property Address Edward Connolly - Owner Owner's Name information is Cohasset MA 02025 10/18/2016 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or.less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r� 346 Old Mill Rd. Marstons Mills, MA 02648 Property Address Edward Connolly Owner Owner's Name information is required for every Cohasset MA 02025 10/18/2016 page. Citylrown 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, I 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): N/A Number of bedrooms(actual): 3 DESIGN flow base d on 310 CM 330pdR 15.203 (for example: 110 gpd x#of bedrooms): 110gpd t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 6 of 17. Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 346 Old Mill Rd. Marstons Mills, MA 02648 Property Address Edward Connolly Owner Owner's Name information is Cohasset MA 02025 10/18/2016 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 0 � Number of current residents: 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2014=120gpd 9 ( Y 9 (gP )) 2015=142gpd Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Date Date 16 Commerciallindustrial 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..3113 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 346 Old Mill Rd. Marstons Mills, MA 02648 Property Address Edward Connolly Owner Owners Name information is required for every Cohasset MA 02025 10/18/2016 page. Citylrown 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: No Records Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? Truck glass Reason for pumping: Maintenance 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): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 346 Old Mill Rd. Marstons Mills, MA 02648 Property Address Edward Connolly Owner Owner's Name information is required for every Cohasset MA 02025 10/18/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Est. 20-30 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 4'4" Depth below grade: feet Material of construction: ❑ cast iron . ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: +10'feet Comments(on condition of joints, venting, evidence of leakage, etc.): Line checked with sewer camera and was found to be clean, properly pitched with no sign of root intrusion. Septic Tank(locate on site plan): 3,6„ 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: 1000Ga1 Sludge depth: 6-8 11 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 346 Old Mill Rd. Marstons Mills, MA 02648 Property Address Edward Connolly Owner Owner's Name information is required for every Cohasset MA 02025 10/18/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 3-5" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Estimated Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1000Gal H-10 tank in good structural condition. Concrete baffles in place and clean. Tank at normal operating level. Covers 3'6" below grade. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 346 Old Mill Rd. Marstons Mills, MA 02648 Property Address Edward Connolly Owner Owner's Name i1formation is Cohasset MA 02025 10/18/2016 required for every page. Cityffown 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 telow 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 Ilast pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 17 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 346 Old Mill Rd. Marstons Mills, MA 02648 Property Address Edward Connolly Owne- Owner's Name information is Cohasset MA 02025 10/18/2016 required for every page. Cityrrown 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 0° Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): H-10 DB-3 with 1 line in and 1 line out in good condition. Box is clean and level with minimal solids carryover. No sign of overloading or hydraulic failure. Cover 6" below grade. 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: 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 346 Old Mill Rd. Marstons Mills, MA 02648 Property Address Edward Connolly Owne- Owner's Name information is required Cohasset MA 02025 10/18/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1-6x6 ❑ 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.): 1-6x6 Leach pit with stone. 2' of effluent in pit at time of inspection with staining no higher. No sign of overloading or hydraulic failure. Cover 3' below grade Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 346 Old Mill Rd. Marstons Mills, MA 02648 Property Address Edward Connolly Owner Owners Name information is required for every Cohasset MA 02025 10/18/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Material's of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): :Sins•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 346 Old Mill Rd. Marstons Mills, MA 02648 Property Address Edward Connolly Owner Owner's Name information is required for every Cohasset MA 02025 10/18/2016 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 346 Old Mill Rd. Marston Mills, MA 02648 Property Address Edward Connolly Owner Owner's Name information is Cohasset MA 02025 10/18/2016 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high round water: +14' p g g feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: pate ® 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: Hand auger to 14'with no water encountered. Bottom of pit at 10'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 346 Old Mill Rd. Marstons Mills, MA 02648 Property Address Edward Connolly Owner Owner's Name information is oequired for every Cohasset MA 02025 10/18/2016 page. City/Town 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 %.AjsqQW"—U,A CGd-,L,' TOWN OF BARNSTABLE LOCATIW1VKI �Ai 22 &4, SEWAGE M VILLAGE ASSESS R'S MAP&LOT—! 4 o -TjY PELWS NAME&PHONE N SEPTIC TANK CAPACITY ;LEACHING FACILITY:(type) 'e,C�h ;� (size)L,iu NO.OF BEDR MS BU)LDER 0 O PERMUE TE: COMP CE 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 ,- I oar cc1�c� L TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date Time: In Out Owner A&I \��1J A J'D 1)N©LL J Tenant Address L t l A &NA 1,&6 Address�Sq b DCP U i u— � Compliance Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilities t 3. Bathroom Facilities ✓ - y �Z 4. Water Supply 5. Hot Water Facilities b v t b ru S ® 7 6. Heating Facilities,,, Or 1�5PGL-f'i 7. Lighting and Electrical Facilities J 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural / Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal 17. Temporary Housing 18. Driveway Width 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms Number of Vehicl Ilow d (ma ) �� Number of Persons Allowed (max) 5 Person(s) Interviewed �tr� �l \ Inspector If Public Building such as Store or Hotel/Motel specify here TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date '110111 Time: In Out Owner e J WA 9 afl/" OU Tenant Address L r L Address 3y6 OL_)I M I L t- C P55 T , YVIRsTON'S ma��.s�MA Compliance Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilities V/ 3. Bathroom Facilities R 4. Water Supply 5. Hot Water Facilities 6. Heating Facilities 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities c V- ( -rV �- 10. Curtailment of Service ✓ 11. Space and Use 12. Exits2(L�c.T� = 13. Installation and Maintenance of Structural / Elements v 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal 17. Temporary Housing p( 18. Driveway Width 19. Number of Tenants Observed �. i PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms Number of Vehicles Allowed (max) Number of Persons Allowed (max) Person(s) Interviewed l�1gIJ Ts Inspector If Pubhc Building such as Store or Hotel/Motel specify here ' TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date b ' ® Time: In Wfoo is Out o ao A. Owner. MA dowok Tenant '1n NG e S 1 c-�i N �i d (� U Ll� �� t , f�ta Address � � � Address ��a � L ilia S C Compliance Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilities f'j , Nv SG RED 2UIJ 3. Bathroom Facilities d r-4-d N t S7 a IS Po o/t, 4. Water SuPPIY J EU t NVA� � I N'l -t ZZ 1 NG4 5. Hot Water Facilities ' f �v 6. Heating Facilities 7. Lighting and Electrical Facilities �`gl�e4c�9��� ks 8. Ventilation 00" NJO-C O .C4A-1 --LCIO"- 9. Installation and Maintenance of Facilities TOAIIC,4s 10. Curtailment of Service ',`T}'1.f z-"0 11. Space and Use 12'. Exits �v :2 S�AI i2S Gro un aC r,c,. 13. Installation and Maintenance of Structural A Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposalf v 16. Sewage Disposal 17. Temporary Housing f/2!f 18. Driveway Width ff" p 19. Number of Tenants Observed j IV PART II td�-�E� /✓l r'SSo'�c7 ® /��a�q 4� 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition -rd $i_f_ Number of Bedrooms 3 -7 3 � Number of Vehicles Allowed (max) 177 scc- Number of Persons Allowed (m x) Sly Person(s) Interviewed _ Inspector •S . If Public Building such as S ore or Hotel/Motel specify here I I . 0 Complete items 1,2,and 3.Also complete A. item 4 if Restricted Delivery is desired. ■ Print your name and address on the reverse ee so that we can return the card to you. Received tinted Name) C. Date Delivery ■ Attach this card to the back of the mailpiece, or on the front if space permits. D. Is delivery address dtffer`e� rn Rem 1 El Yes 1. Article Addressed to: e— If YES,enter delliive' address be iow:/ ❑No 1"(" @'. , & \ Ll Iti P0'r0- 4PR2220 3. Service Type ❑Certified Mai4022umpRec�ilpt all❑Registered for Merchandise ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number -- ----_ _ , (Transfer from seMce.labeQ :7 D 6 215 0 0 p 0 2 1'0 41 2 915 0 €' 1 PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540 UNITED STATES POSTAL SERVICE I d I Jr Pfv [ ;:Y.q h3 f� ii(e t ! ;�� a � r $a,9@HPttt `: e A,4..1)171' 2'11ti.i'X 4 471 N'; ........... • Sender. Please print your name, address, and ZlP+4—Vri4h5i's box • Town of Barnstable Health Division 200 Main Street Hyannis, MA 02601 p �. • V'1 Ir ra - r� M 0 Postage $ r=l Certified Fee n.l Postmark p Return Receipt Fee Here p (Endorsement Required) a, ' p Restricted Dellvery Fee (Endorsement Required) p r=l Total Postage&Fees $ 1 C f1J ent lo �� ��n�y n,� \+ C3 y i5..lN...ec..Wrl!_!M1L`-._ Street,Apt. o.;t _ r. or PO Box No. J ��^ L �(u City State,ZIP+4' =k ._7/V,`.......:.................................. Certified Mail Provides: a A mailing receipt o A unique identifier for your mailpiece n A record of delivery kept by the Postal Service for two years Important Reminders: e Certified Mail may ONLY be combined with First-Class Maile or Priority Mail®. o Certified Mail is not available for any class of international mail. n NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. a For an additional fee,a Return Receipt may be requested to provide proof of. delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required. a For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". is If a postmark on the Certified Mail receipt Is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present It when making an inquiry. PS Form 3800,August 2006(Reverse)PSN 7530.02-000.9047 I Certified Mail#7006 2150 0002 1041 9150 zNE rower Town of Barnstable_ �Il--( i '�l Regulatory Services BARNSTABLE.I! iJ MASS. m/' Thomas F. Geiler, Director . OA ri6gq�¢, �\ lfD MA / Public Health Division U Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 April 18, 2008 Mary & Edward Connolly 1 Lily Pond Lane Cohasset, MA 02026 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY CODE II — MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE CODE CHAPTER 170. The property owned by you located at 346 Old Mill, Marstons Mills 02648, was inspected on April 17, 2008 by Donald Desmarais, Health Inspector for the Town of Barnstable. This inspection was conducted on the basis of the rental registration in accordance with Chapter 170 of the Town of Barnstable Code. The following violations of the State Sanitary Code were observed: 105 CMR 410.503(A) -Protective Railings and Walls Railing needs to be repaired. 105 CMR 410.482—Smoke Detectors Smoke detectors were inoperative upstairs and downstairs. 105 CMR 410.351(A) — Owner's Installation and Maintenance Responsibilities Upstairs bathroom sink clogged You are directed to correct the violations listed above within thirty (30) days of your receipt of this notice by repairing the railing, smoke detectors and bathroom sink. QAOrder letters\Housing violations\Rental ordinance\346 Old Mill Lane.doc y You may request a hearing before the Board of Health if written petition requesting same is received within ten (10) days after the date the order is served. Non-compliance will result in a fine of $100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation. Should you have any questions regarding the above violations, please contact the Town Health Division and ask to speak with the inspector who performed the inspection. PE,Y,Q,RVTW O THE BOARD OF HEALTH V4 T mas A. McKean, R.S., C Director of Public Health Town of Barnstable Cc: Health Inspector Q:\Order letters\Housing violations\Rental ordinance\346 Old Mill Lane.doc FORM3O HIW HOBBSBWARREN'. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH CITY/TOWN o DEPARTMENT 'o ADPIAESS G^M Sy\0� i /, / II TELEPHONE Address 3616 O C&m IJ m--Occupant_. Floor Apartment No. -No. of Occupants No.of Habitable Rooms No.Sleeping Rooms No.dwelling or rooming units No.St ries_ /-� Lug �• ��Q�J �. Name and address of owner_ r�— l n- Q� Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: B ❑ F ❑ M Doors,Windows.- Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Li htin STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N E ui . Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) LECTRICAL Panels, Meters,Cir.: JENJI0 ❑ 220 Fusing,Grnd.: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Living Room Bedroom(1), Bedroom 2 Bedroom 3 w/ Bedroom 4) Hot Water Facil. SupTen.C26sPil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "T INSP ON REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND P AL JURY." INSPE TOR TITLE A.M. DATE TIME P.M. A.M. THE NEXT SCHEDULED REINSPECTION P.M. ` . ' ~ Conditions Deemed to Endanger The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or impair the heaith, or safety and well-being of a person or persons occupying the premises. This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter |i 1O5CIVIR410.1OO through 41O.02Ootate minimum requirements of fitness for human habitatmn, any other violation has the potential to fall within this category in any given specific situation but may not d000 in every uamo and therefore is not included in this listing. Failure to include shall in noway be construed aoa determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair orcorrection of such violation(s) pursuant to 105 CIVIR 410.830thmugh 410.833 nor shall failure ty include affect the legal obligation of the person to whom the order is issued to comply with such order. ' (A) Failure Vn provide asupply of water sufficient in quantity, pressure and temperature, both hot and cold, tu meet the ordinary needs of the occupant in accordance with 105CMR 410.180and 41U.19U for a period cd24 hours orlonger. � � (B) Failure m provide heat ao required by1O5CMR41O.201 o/improper venting o/ use ofo space heater or water heater aa prohibited by 1O5CMR410.280(8)and 410202. ~ (C) Shutoff and/or failure 10 restore electricity mgas. (D) Failure Vn provide the electrical facilities required by1U5CMR41O.25U(B), 410.251(A). 41O.253 and the lighting incom- mon area required by 105CIVIR410254. (E) Failure 10 provide a safe supply ofwater. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 41U.15O(A)(1)and 410.3OU. (G) Failure to,provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage ortrash, which prevents egress in case ofan emergency 105 CIVIR 410.450. 410.451 and 410.452. (H) 'Failure Vu comply with the security requirements W 105 CMR 410.480(D). (|) Failure 0z comply��Uh any pmvoionoof105C�R41O.60O. 410.GO1ox41O.8O2 which mmuhain any aooumu|ahonofga` bago. mbb�h.ji|thor'other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute m accidents orito the creation or spread of disease. (J} The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 OMR 460.000. (See M.Gl.r. 111 @6D1QO through 1QSj ` (K) Roof, foundation, mother structural defects that may expose the occupant manyone else to fire, burns, shock, accident or other dangers or impairment to health orsafety. (L) Failure to install o|eotrival, p|umbing, heating and gas-burning bmi|hiau in accordance with accepted p|umbing, hoating, gas-fitting and electrical wiring standards or failure Vo maintain such tmi|ti*waa are required by 105 CIVIR 410.351 and 410.352. noaeto expose the occupant 4r anyone else tofire, bumo, uhook, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the ed000e of asbestos dust orwhich may result inthe release of powdored, crumbled o/ pulverized asbestos material in violation of 105 CMR410.353. (N) Failure to provide u smoke detector required by 105 CIVIR 410.482. (0) ` Any of the following conditions which remain uncorrected for a period of five o/ more days following the notice toor `-knowledge of the owner of said condition orconditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven o/any defect that renders either inoperable. (2) Failure to provide uwashbasin and shower nr bathtub aorequired in 105 CIVIR 410.150(A)(2)and 410.15O(A)(3)orany defect which renders them inoperable. , (3) Any defect in the electrical, plumbing m heating which makes such'system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that�dom�oma�animmedi�ehuza�. � (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as � required by 105CMR410.503V\ and 410.503(B). (5) Failure Vo eliminate rodents, 000kmaohem, insect infestations and'other pests aurequired by 105CMR410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CIVIR 418.750KQ through (})ohu| be deemed to be a con- dition whichmayondangorormateriaUyimpgirthohealdknruafetyandwoU'b*ingofan000upmntuponthofai|umof#heowner 0o remedy said condition within the time oo ordered hy the Board ofHealth. � . ' . ' . ` . ` 1 ?m y$ I f 3 �m COMMONWEALTH OF MASACHUSETTS O EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION "-P ! ONE WINTER STREET BOSTON MA 02108(617)292-3500 - TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Govemor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 346 OLD MILL RD MARSTONS MILLS, MA 02648 U`'KKl � oM 00 l Name of Owner EDWARD CONNELLY Address of Owner: 1 LILY POND LANE COHASSET MA.02026 Date of Inspection: 7/26100 Name of Inspector: JOHN GRACI I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: SEPTIC INSPECTIONS Mailing Address: P.O.BOX 2119 TEATICKET,MA.02636 Telephone Number: 608-664-6813 FAX 608-564-7270 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Passes _ Conditionally Passes _ Needs Further Evaluation y the Local Approving Authority Fails Inspector's Signature: t! Date:7/26/00 The System Inspector shall sub it a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection.If th 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,if4pplicable,and the approving authority. NOTES AND COMMENTS "The inspection is based on criteria defined in Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.My inspection does not imply any warranty or guarantee of the longevity of the septic system and any of its component's useful life." THE SYSTEM PASSES TITLEV IN C ION.RECOMMEND PUMPING THE SYSTEM NOW AND EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE.. 0�_ revised 9/2198 Page 1 of 11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 346 OLD MILL RD MARSTONS MILLS, MA 02648 Name of Owner EDWARD CONNELLY Date of Inspection: 7/25/00 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. nLa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank, whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. nLa Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). _broken pipe(s)are replaced _obstruction is removed _distribution box is levelled or replaced Wa The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if (with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) F . Property Address: 346 OLD MILL RD MARSTONS MILLS, MA 02648 Name of Owner EDWARD CONNELLY Date of Inspection: 7/26/00 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: jE The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is-equal to or less than 5 ppm,Method used to determine distance n(a(approximation not valid). 3) OTHER n/a revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 346 OLD MILL RD MARSTONS MILLS, MA 02648 Name of Owner EDWARD CONNELLY Date of Inspection: 7126/00 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. - X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped 0. _ X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, - X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.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: ,.;, You must indicate either"Yes"or"No"to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2198 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 346 OLD MILL RD MARSTONS MILLS, MA 02648 Narne of Owner: EDWARD CONNELLY Dale of Inspection: 7/26/00 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health. X - None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with NIA. X - The facility or dwelling was inspected for signs of sewage back-up. X - The system does not receive non-sanitary or industrial waste flow. X _ The site was inspected for signs of breakout. X - All system components,excluding the Soil Absorption System,have been located on the site. X _ The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X - Existing information,For example,Plan at B4O,H, X _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)15.302(3)(b)) X _ The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 346 OLD MILL RD MARSTONS MILLS, MA 02648 Name of Owner EDWARD CONNELLY Date of Inspection: 7/26/00 FLOW CONDITIONS RESIDENTIAL: Design flow: 110 g.p.d./bedroom Number of bedrooms(design): 3 Number of bedrooms(actual): Total DESIGN flow: 330 gpd Number of current residents:3 Garbage grinder(yes or no):NO Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no): NO Seasonal use(yes or no): NO Water meter readings,if available(last two year's usage): n/a gpd Sump Pump(yes or no): NO Last date of occupancy: n/a C O M M ERC IAL/I N DUST RIAL Type of establishment: n/a Design flow: n/a gpd(Based on 15.203) Basis of design flow:n/a Grease trap present:(yes or no): NO Industrial Waste Holding Tank present:(yes or no): NO Non-sanitary waste discharged to the Title 5 system:(yes or no):NO Water meter readings.if available: n/a Last date of occupancy:n/a OTHER: (Describe) n/a GENERAL INFORMATION PUMPING RECORDS and source of information: 1996 System pumped as part of inspection:(yes or no):NO If yes,volume pumped n/a gallons Reason for pumping:n/a TYPE OF SYSTEM X 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) _ VA Technology etc.Attach copy of up to date operation and maintenance contract _ Tight Tank Copy of DEP Approval Other:n/a APPROXIMATE AGE of all components,date installed(if known)and source of information: 1986 Sewage odors detected when arriving at the site:(yes or no) NO revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 346 OLD MILL RD MARSTONS MILLS, MA 02648 Name of Owner EDWARD CONNELLY Date of Inspection: 7/26/00 BUILDING SEWER:X (Locate on site plan) Depth below grade: 48" Material of construction: _ cast iron X 40 Pvc _ other(explain) Distance from private water supply well or suction line: n/a Diameter: n/a Comments: (condition of joints,venting,evidence of leakage,etc.) THERE IS TOWN WATER SEPTIC TANK: X (locate on site plan) Depth below grade: 42" Material of construction: X concrete_ metal_ Fiberglass_ Polyethylene_ other explain: n/a If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO Age: n/a Dimensions: 1000 GALLON H10 PIT" Sludge depth: 3" Distance from top of sludge to bottom of outlehee or baffle: 31" Scum thickness: 2" Eit Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: n/a How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING NOW AND EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. GREASE TRAP: _ (locate on site plan) Depth below grade: n/a 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 Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) n/a " of , revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 346 OLD MILL RD MARSTONS MILLS, MA 02648 Name of Owner EDWARD CONNELLY Date of Inspection: 7/26/00 TIGHT OR HOLDING TANK: _ (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: n/a Material of construction: _concrete_ metal_Fiberglass _Polyethylene _other Explain: n/a Dimensions: n/a Capacity: n/a gallons Design flow: n/a gallons/day Alarm present: NO Alarm level:N/A Alarm in working order:NO Date of previous pumping: n/a Comments: (condition of inlet tee,condition of alarm and float switches,etc.) n/a DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: n/a Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) n/a PUMP CHAMBER: _ (Iodate on site plan) Pumps in working order:(Yes or No): NO Alarms in working order(Yes or No): NO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) n/a revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 346 OLD MILL RD MARSTONS MILLS, MA 02648 Name of Owner EDWARD CONNELLY Date of Inspection: 7/26/00 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: n/a Type: leaching pits,number:(1)1000 GAL 6'X 6' leaching chambers,number: (n/a)n/a leaching galleries,number: (n/a)n/a leaching trenches,number,length: (n/a)n/a leaching fields,number,dimensions: (n/a)n/a overflow cesspool,number: (n/a)n/a Alternative system: n/a Name of Technology: n/a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING PROPERLY.THE PIT HAD 2'OF LEACHING LEFT AT THE TIME OF THE INSPECTION.RECOMMEND RAISING THE COVER TO THE PIT-IT IS 48"TO GRADE. CESSPOOLS: _ (locate on site plan) .,.a;., 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: n/a inflow(cesspool must be pumped as part of inspection)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 9 Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n/a revised 9/2/98 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 346 OLD MILL RD MARSTONS MILLS, MA 02648 Name of Owner EDWARD CONNELLY Date of Inspection: 71261'00 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) I�f ' v 4 I reused 912/98 Page 10 of 11 { SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 346 OLD MILL RD MARSTONS MILLS, MA 02648 Name of Owner EDWARD CONNELLY Date of Inspection: 7/25/00 NRCS Report name: n/a Soil Type: n/a Typical depth to groundwater: n/a USGS Date website visited: n/a Observation Wells checked: NO Groundwater depth: Shallow_ Moderate_ Deep_ SITE EXAM _ Slope _ Surface water _ Check Cellar _ Shallow wells Estimated Depth to Groundwater 12 Feet+ Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions Checked with local Board of health _ Checked FEMA Maps Checked pumping records Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS-12+FEET revised 9/2/98 Page 11 of 11 �g/as COMMONWEALTH OF MASSACHUSETTS r EXECUTIVE OFFICE OF :N MENTAL AFFAIRS DEPARTMENT OF ENV �I>1MENTAL ROTECTION i 34 y� 1 Gj ---�, TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address. p Owner's Name: Owner's Address: c� a� Date of Inspection: Name of Inspe please print Company Nam- — Mailing Address: ILA Telephone Number: Kul'' 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 toSection 15.340 of Title 5(31C CMR 15.000). The system: ✓ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority ails Inspector's Signature: Date: The system inspector shall ubmit a copy of this inspection report to.the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority.Notes and Comments '11411 lee ib ce-14e111— A&Azle W/�4 sore celxo 61Jry , 5�e4,IW. 6 e �a��he� .e 3 ` ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address., l-(,_�,,� Owner&z ' Date of Inspecti6 on: Inspection Summary: Check A,B,C,D or E./ALWAYS complete all of Section D A. System Passes: i/ I have not found any information which indicates that any of the failure-criteria,described.in„310.CMI2.. 15:303 or'iri'310`CMR 15.3.04 exis-t.An}:failure criteria not evaluated are indicated below. Comments: M System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing.tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to.a broken, sealed 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 11 OFFICIAL INSPECTION FORM - NOTTOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: ( �� Owne R _ 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:" Systeurwill pass unless Board of Health determines n 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 I 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 tite 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 DAP 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 Pace 4 of 11 OFFICIAL-INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property P y Address Owners Date of InsP ection• 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.clo6Qed 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 l cesspool _ ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the 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 p.ubiic 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 acceptaole 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 amiuonia nitrogen and nitrate nitrogen.is equal to or less than 5 ppnt, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] �V (Yes/No)The system fails: 1 have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact.the Board of Health to.determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the.criteria above) yes no . the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 r Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART:B` CHECKLIST Property Address: Owner: dA/ 2 Date of Inspection: 71 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes o r Pumping.information.was provided by the owner,occupant,o':Board of,Health - (//Were.any of the system components pumped out in the previous two weeks? C/ Has the system received normal.flows in the previous two week period ? (/ Have large-volumes of water been introduced to the system recently or as part of this inspection ? Were as built plans of the system obtained and examined?(If They were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up (� Was the site inspected for signs of breakout? Were all system components, excluding the SAS, located on site Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of tl e baffles or tees,material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? _ Was.the facilityowner and occupants if different from owner provided with information on the proper ( 1 )P P P 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. V _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] h 5 Page 6 of 11 OFFICIAL INSPECTI N�O I'OIZM-- NOT I OR VOLUNTARY ASSI;SSMIJNTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM INFOIZMATION Property Address:( All Owner d/. Date o Inspection• u FLOW CONDITIONS RESIDENTIAL ✓� Number of bedrooms(design):—a. Number of bedrooms(actual): DESIGN flow based on 310:CMR 15.203 (for example: 11.0 gpd x#of bedrooms):� Number of current residents: Does residence.have.a garbage grinder(yes or no): Is laundry on a separate sewage system (y s or no)x .[if yes separate inspection required] Laundry system inspected (ye/s or no):/ Seasonal use: (yes or no):N0 . Water meter readings; if ava lable(last.2 years usage(gpd)): ®`'1--Z;000 Sump pump(yes or � Last date of occupancy: �e�t- - L/2G � COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR.15.203): gpd Basis of design.flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(;yes or no): Non-sanitary waste discharged to the Title 5 system (yes or no):-_ Water meter readings, if available: Last date of occupancy/user OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:if , yz/ �5�� - t�kV� Wassystemgum edas arto-fthei es.orno U If yes, volume pumped; . . gallons--1low was quantity pumped 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 froni system owner) _Tight tank _Attach a copy ofthe'D) P.approval Otlier(describe): (� � � f,f►� A roximate age of all components, date installed(if known) and source of information: Were sewage odors detecte when arriving at the site(yes or no ti i Page 7 of; 1 ` OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner. _ Date of Inspection: S BUILDING SEWER(locate on site plan)xe) Depth below grade: Materials of construction:_cast iron ' 40 PVC_other(explain): Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage,etc.): E TI TANK: V. locate S P C ��a����n sit,e ]an) Depth below grade: - Material of constructio _pd crete_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) r � Dimensions: ` Sludge depth: �P Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: P1 Distance from top of scum to top of outlet tee or baffle: r� Distance from bottom of scum to bottom of outlettee or baffle: �� ✓P How were dimensions determined �� 1o�$/�i{�_, ° /J'►" Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels related to outlet invert, evidence of leakage,etc.): o C�C1c� ,� ) �a)i � 2 � f�` � �i�p'>�'•-�—C1—�-�;��. �.��,�,,.,1�� ,g ems. GREASE TRA :&locate on site,plan) Jrz pt /� I .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 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property Address: Ovine :- 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 otlier(explain): Dimensions: Capacity: gallon_ 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.): \ t DISTRIBUTION BOX: (if present.must be opened)(locate on site.flan) 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 CHAMBII[ � (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.): i Page 9 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMAATION(continued) Property Address: 2 �' Owner: Q _ R- Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why: Ty y leaching 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 por_ding, damp soil,condition of vegetation, ' c / ,. ri > l CESSPOO (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: AJ Indication of groundwater 'inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc:): PRIV�(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.): 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 Address:. � G Owner• t � Date of Inspection ems , 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: IK . P PP �U J too W1L 10 w Page 11 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) l l .Property Address: w 1�C9-dd Owner: «fill Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells i Estimated depth to ground water 20 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: s -- 11 Permit Number: Date:_ Y' Com feted ^P b HIGH GROUND-WATER LEVEL COMPJTATION Site Location: Lot No. Owner:- / 6,-: lee Address: Contractor: /z l �,�` Address: Notes: STEP 1 Measure depth to wager table tonearest 1/10 ft. ............................................................................ Date month/day/year STEP 2 Using Water-Level Rarge Zone and Index Well Map Ixate = site and determine: - OAppropriate inde?c well............:....... (/B, Water-level range zone ..... ............................................ ... L� STEP 3 Using monthly report.`'Current Water Resources..Cond tions" determine current depth to water level for index ,,III ........................... J��` 'f month/year STEP 4 Using Table of Water-evel AdjustmentsF - for index well (STEP 2A), current depth to water level for inde?:,well (STEP 3), and water-level zone (STEP 2B) determine water-level .adjustment ............ 1t......................................................... 4r t STEP 5 Estimate depth to high Water - by subtracting the water- level adjustment (STEP 4) from measured depth to water level at site (STEP 1) ........................................... ..................................... .. x 4 } ! t t Figure 13.--Reproducible computation form. r b 2: 15 II lead". r � Y I • I t