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HomeMy WebLinkAbout0020 RASCALLY RABBIT ROAD - Health 20 Rascally Rabbit', Qtcal�:.. Marstons Mills P .� = 078 069001 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS I DEPARTMENT OF ENVIRONMENTAL PROTECTION e C i r y V• TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 20 Rascally Rabbit Road Marstons Mills Owner's Name: Russell Berg Owner's Address: Date of Inspection: 8/16/2005 S� `3k Name of Inspector: (please print) Patrick T. Sullivan 'i Company Name: Ready Rooter Mailing Address: P.O. Box 371 C)¢ ' Sandwich, MA 02563 Telephone Number: (508)888-6055 1 co CERTIFICATION STATEMENT v-, I certify that I have personally inspected the sewage disposal system at this address and that the d formation reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(31.0 CMR 15.000). The System: Passes Conditionally Passes Needs Further Evaluation by the Local Authority Fails Inspector's Signature: Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. 1 . Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 20 Rascally Rabbit Road Marstons Mills Owner: Russell Berg Date of Inspection: 8/16/2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D C. 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. l 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 structural-ly sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or.:dneven 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;rnore than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval ofthe Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 2'0 Rascally Rabbit Road Marstons Mills Owner: Russell Berg Date of Inspection: 8/16/2005 C. Further Evaluation is Required by the Board of Heal Conditions exist which require further evaluation�j"the Board of Health in order to determine if the system is failing to protect public health,safety or the environ tsnt. 1. System will pass,unless Board of Health termines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner ich will protect public health,safety and the environment: _Cesspool or privy is within 50 fe of a surface water Cesspool or privy is within 50 et of a bordering vegetated wetland or a salt marsh 1 2. System will fail unless the Board of Health(and Public Water Supplieryf any)determines that the system is functioning in a manner that protects the public health,safety and nvironment: _The system has a septic tank and soil absorption system(SAS)and e 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 alone 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. I _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 di tance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the ell is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is/ qual to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis mu t be attached to this form. 3. Other: i Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 20 Rascally Rabbit Road Marstons Mills Owner: Russell Berg Date of Inspection: 8/16/2005 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 _ _Z 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 and overloaded or clogged SAS or cesspool _,Z Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow I/ 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 I of a public well. _ Any portion of a cesspool or privy is 50 feet of a private water supply well. _✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. ]This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails. I have determined that one or more of the above 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: l To be considered a large system the system must serve a face4di 3y with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the folloyding: (The following criteria apply to large systems in additio�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 trif�utary to a surface drinking water supply the system is located in a nitroger(sJJensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well f If you have answered"yes"to any gdestion 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 Y or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner sho 1d contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 20 Rascally Rabbit Road Marstons Mills Owner: Russell Berg Date of Inspection: 8/16/2005 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? _ -Z 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 than owner)provided with information on the proper maintenance of subsurface sewage disposal systems? I The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No _ Existing information.For example,a plan at the Board of Health. _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 20 Rascally Rabbit Road Marstons Mills Owner: Russell Berg Date of Inspection: 8/16/2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number'of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 Qdexample: 110 gpd x#of bedrooms): Number of current residents: / Does residence have a garbage grinder.(yes or no):_ Is laundry on a separate sewage system(yes or no):_[if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no): Water meter readings, if available(last 2 years usage(gpd)): Sump Pump(yes or no): Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: c,-e— Design flow(based on 310 CMR 15.203): ''1 1 oZ gpd Basis of design flow(seats/persons/sq. ft.etc.): !J.<OVQ 15V , , Grease trap present(yes or no): ,2p Industrial waste holding tank present(yes or no):P—A=� Non-sanitary waste discharged to the Title 5 system(yes or no):Ap Water meter readings, if available:%Q., 03 --7 SY C9. P.ZJ, Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): 0Cp If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): tJ Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 20 Rascally Rabbit Road Marstons Mills Owner: Russell Berg Date of Inspection: 8/16/2005 BUILDING SEWER(locate on site plan) Depth below grade: 30` Materials of construction:_cast iron ,/ 40 PVC_other(explain): Distance from private water supply well or suction line: Fllx/- Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓(locate on site plan) Depth below grade: Material of construction: V concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: \ x (6 " x , A' c7 Sludge depth: " Distance from the top of sludge to bottom of outlet tee or baffle: 3 Scum thickness: i it Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: ! 7� How were dimensions determined: Comments(on pumping recommendations'inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): GREASE TRAP:_(locate on site plan) ) Depth below grade: Material of construction:_concrete metal_fiberglass_polyethylene_other (explain): s` Dimensions: Scum thickness: Distance from top of scum to top,,6 outlet tee or baffle: Distance from bottom of scum tlo�bottom of outlet tee or baffle: Date of last pumping: / Comments(on pumping rec9fnmendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, idence of leakage,etc.): r Page 8 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 20 Rascally Rabbit Road Marstons Mills Owner: Russell Berg Date of Inspection: 8/16/2005 TIGHT or HOLDING TANK: (tank must beIpumped at time of inspection)(locate on site plan) Depth below grade: Material of construction:_concrete—metal_fiberglass_polyethylene_other(explain): Dimensions: Capacity: gallon's Design Flow: gal-Pons/day Alarm present(yes or no): Alarm level: Alarm in Working order(yes or no): Date of last pumping: / Comments(condition of ala7 and float switches,etc.): DISTRIBUTION BOX: L/(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Q" Comments(not 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 or no): ;f Alarms in working order(yes or no): / Comments(note condition of pump chamber/condition of pumps and appurtenances,etc.): Page 9 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 20 Rascally Rabbit Road Marstons Mills Owner: Russell Berg Date of Inspection: 8/16/2005 SOIL ABSORPTION SYSTEM (SAS):_j,!!0f(locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: /leaching galleries,number: � g 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.): 3 CESSPOOLS: (cesspool must be pumped as part o mspection)(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): Comments(note condition of soil,si s of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil, sig of hydraulic failure, level of ponding,condition of vegetation,etc.): Page 10 of 11 OF FICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 20 Rascally Rabbit Road Marstons Mills Owner: Russell Berg Date of Inspection: 8/16/2005 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. C S0--, _ - - - -- -1 F- 0 L4 L( ol JL, J �1 ( � L C C 21 7�, Page I 1 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 20 Rascally Rabbit Road Marstons Mills Owner: Russell Berg Date of Inspection: 8116/2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water> feet Please indicate(check)all methods used to determine the high ground water elevation: V Obtained from system design plans on record—If checked,date of design plan reviewed: )9 C:) Observed site(abutting property/observation hole within 150 feet of SAS) Checked with the 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: n ' s COMMONWEALTH OF MASSACHUSETTS Z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION h f.t gV �s TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION R�� 1 � Property Address: 20 Rascally Rabbit Road,Marstons Mills,(Office Bldg) Owner's Name:BVTV Inc. APR 5 2002 Owner's Address:30 Rascally Rabbit Road,Marstons Mills TOWN OF BARNSTABLE Date of Inspection: 04/12/02 HEALTH DEFT. Name of Inspector:Brian T.Axon L 4D^1 Company Name:A&K Septic Systems Plus 1 Mailing Address:565 Carriage Shop Road East Falmouth,MA 02536 MAP we Telephone Number:508-540-6706 PARCEL ; O(99 bo 1 LOT CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems..I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 04/16/02 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments: System functioning fine.There is no evidence of failure criteria. System consists of 2000 gallon septic tank with d-box and 8'x 36'leaching trench with flow galleries and 2'of stone. ****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. f Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:20 Rascally Rabbit Road(Office) Owner:BVTV Inc. Date of Inspection:04/12/02 Inspection Summary: Check A B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is.available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: r Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 20 Rascally Rabbit Rd,(office) Owner:BVTV Inc. Date of Inspection:04/12/02 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**.Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 20 Rascally Rabbit Rd(office) Owner:BVTV Inc. Date of Inspection:04/12/02 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No x Backup of sewage into facility or system component due to 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'/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 x Any portion of the SAS,cesspool or privy is below high ground water elevation. x Any portion of 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 1 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. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a niimifinnn4 t1—+—A—Q—"-R nr fniln`1.-4—Q—tinn n o1_11 nrrm.iin tl�w c..n4nm in nnnnriinnro. 41, 111)rT%AD 'Page 5of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 20 Rascally Rabbit Road(office) Owner:BVTV Inc. Date of Inspection: 04/12/02 Check if the following have been done.You must indicate`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 Were any of the system components pumped out in the previous two weeks X _ Has the system received normal flows in the previous two week period X Have large volumes of water been introduced to the system recently or as part of this inspection X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up X _ Was the site inspected for signs of break out X _ Were all system components,excluding the SAS,located on site X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the taffies or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X _ Existing information.For example,a plan at the Board of Health x _ 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)J ' Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:20 Rascally Rabbit Road(office). Owner:BVTV Inc. Date of Inspection:04/12/02 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):Number of bedrooms(actual) DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no):no Is laundry on a separate sewage system(yes or no):no [if yes separate inspection required] Laundry system inspected(yes or no):NO Seasonal use: (yes or no): Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no):no Last date of occupancy: COMMERCIALANDUSTRIAL Type of establishment:Office Building Design flow(based on 310 CMR 15.203): 712 gpd Basis of design flow(seats/persons/sgft,etc.): 9842 Sq.Ft. 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): Water meter readings,if available:033522 Last date of occupancy/use: current OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no):NO If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: 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) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information:Feb 1990,town records Were sewage odors detected when arriving at the site(yes or no):NO Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:20 Rascally Rabbit Rd(ofce). Owner:BVTV Inc Date of Inspection: 04/12/02 BUILDING SEWER(locate on site plan) 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.): SEPTIC TANK: x (locate on site plan) Depth below grade: 12" Material of construction: x concrete_metal_fiberglass_polyethylene --other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions:6'x 12'x 6'6" Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle:41" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: I I" Distance from bottom of scum to bottom of outlet tee or baffle: I I" How were dimensions determined:Field instruments Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Recommend pumping every two years. Structural integrity is fine.Liquid levels in relation to tees are fine.There is no evidence of leakage. GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet.tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 20 Rascally Rabbit Road(office) Owner:BVTV Inc. Date of Inspection:04/12/02 TIGHT or HOLDING TANK (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: z (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.): Distribution is equal.There is no sign of leakage or any evidence of solids carryover. PUMP CHAMBER: (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 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 20 Rascally Rabbit Road(office) Owner:BVTV Inc. Date of Inspection:04/12102 SOIL ABSORPTION SYSTEM(SAS): x (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: x leaching galleries,number:8'x 36' 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.): Condition of soil and vegetation is fine.There is no sign of hydraulic failure.Leaching was dry. 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 or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): I Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 20 Rascally Rabbit Rd(office) Owner:BVTV Inc. Date of Inspection:04/12/02 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. Porn IGPt i ��F�Ce (31dy, Shop Frc A 3 a` v'+ a 3 Q C m n Q COP"far fJ�uff B1� ' AD 35 F5D co i 4'� A F 5a' F—T 0 E Sg' AC 7►' OF 5'F A& a�'G° f - Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 20 Rascally Rabbit Road(office) Owner:BVTV Inc. Date of Inspection:04/12/02 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: X 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: Test done prior to installation in February 1990 shows no groundwater at 12+feet. 7 $ C �b ,I COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS A d DEPARTMENT OF ENVIRONMENTAL PROTECTION 4 A A Q '' yV TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTE EIVED PART A CERTIFICATION APR 2 5 2002 Property Address: 20 Rascally Rabbit Rd(Barn) TOWN OF BARNSTABLE Owner's Name:BVTV Inc. HEALTH DEPT. Owner's Address:30 Rascally Rabbit Road,Marstons Mills,MA 02648 Date of Inspection:04/12/02 OAP Name of Inspector:Brian T.Axon PARCEL .'�0 69 Company Name:A&K Septic Systems Plus LOT _ Mailing Address:565 Carriage Shop Road East Falmouth,MA 02536 Telephone Number: 508-540-6706 t4-0j1% CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: 1 Date: 04/16/02 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments: System functioning fine.There is no evidence of failure criteria. System consists of 1000 gallon septic tank with d-box and 600 gallon leaching pit with 2' of stone. ****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. r Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 20 Rascally Rabbit Rd(barn) Owner:BVTV Inc. Date of Inspection:04/12/02 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional.Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined'please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: { Page 3 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 20 Rascally Rabbit Road(barn) Owner:BVTV Inc. Date of Inspection:04/12/02 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not.functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**.Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 20 Rascally Rabbit Road(barn) Owner:BVTV Inc. Date of Inspection:04/12/02 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No x Backup of sewage into facility or system component due to 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%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 x Any portion of the SAS,cesspool or privy is below high ground water elevation. x Any portion of 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 1 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. [This system passes if the well water analysis, performed at aDEP 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.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310�CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed The owner or operator of any large system considered a �im+i�innn4 41+run}..n�nr Canfi nn F nr fniln'1�,nilur Cnnfinn Tl rl�nll nrrmilla fhu r<.cfnm in nnnnrrlonnn nntl, 1 In MAD Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 20 Rascally Rabbit Rd(barn). Owner:BVTV Inc. Date of Inspection:04/12/02 Check if the following have been done You must indicate"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 Were any of the system components pumped out in the previous two weeks X Has the system received normal flows in the previous two week period X Have large volumes of water been introduced to the system recently or as part of this inspection X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up X _ Was the site inspected for signs of break out X _ Were all system components,excluding the SAS,located on site X _ 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 X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no Existing information.For example,a plan at the Board of Health. x _ 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)] Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:20 Rascally Rabbit Road(barn) Owner:BVTV Inc. Date of Inspection:04/12/02 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):I Number of bedrooms(actual): 1 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x 4 of bedrooms): 110 Number of current residents:2 Does residence have a garbage grinder(yes or no):no Is laundry on a separate sewage system(yes or no):no [if yes separate inspection required] Laundry system inspected(yes or no):NO Seasonal use: (yes or no):no Water meter readings,if available(last 2 years usage(gpd)):005831 Sump pump(yes or no):no Last date of occupancy:current COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203):gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no):NO If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: 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) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information:5+years,town records Were sewage odors detected when arriving at the site(yes or no):NO Par,e 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 20 Rascally Rabbit Road(barn) Owner:BVTV Inc. Date of Inspection:04/12/02 BUILDING SEWER(locate on site plan) 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.): SEPTIC TANK: x (locate on site plan) Depth below grade: 12" Material of construction: x concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 5'7'x 8'6"x 4'10" Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 26" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: T' Distance from bottom of scum to bottom of outlet tee or baffle: 8" How were dimensions determined:Field instruments Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Recommend pumping every two years.Liquid levels in relation to tees are fine. Structural integrity is fine.There is no evidence of leakage. GREASE TRAP:_(locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): ilk Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 20 Rascally Rabbit Road(barn) Owner:BVTV Inc. Date of Inspection:04/12/02 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: x (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:W Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): Distribution is equal.There is no evidence of leakage or solids carryover. PUMP CHAMBER: (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 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 20 Rascally Rabbit Road(barn) Owner:BVTV Inc. Date of Inspection:04/12/02 SOIL ABSORPTION SYSTEM(SAS): x (locate on site plan,excavation not required) If SAS not located explain why: Type X leaching pits,number: 1 leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): Condition of soil and vegetation is fine.There is no evidence of hydraulic failure.600 gallon leaching pit was dry at the time of inspection. 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 or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 20 Rascally Rabbit Road(barn) Owner:BVTV Inc. Date of Inspection:04/12/02 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. 3G�., Q^nc�r,cnt IN 0 o AC a►14" (3C 3' 311 D Afl 31- i3p ' E AE 3Y, r QE 3L�q� Shop ! fi f f Page l l of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 20 Rascally Rabbit Road(barn) Owner:BVTV Inc. Date of Inspection:04/12/02 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: X 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: Test it "p shows no groundwater at 144+ . r S�