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Home My WebLink About1990 MAIN ST./RTE 6A(W.BARN.) - Health 1990 Main Street West Barnstable A= 2 i 7-015 I C /RO,IV4,,fY` eree7 9 . a Shed/Boat House i I (Located to the rear of Garage) Deck �- 9 5 g® law am am Un i I { Bath b C3 Bedroon-, Master Bedroom Library C �c E: 1 Bedroom Bedroom/Stud- C 1990 Main Street, West Barnstable f: t; I =E . (. Deck Breakfast Room Kitchen Dining Room Sunroom/Den Garage 26 v Deck �"` -- Living Room Commonwealth of Massachusetts q _ Title 5 Official Inspection Form ;j i; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments C , -�a 1990 Main st/ Rt 6A Property Address - - Debra A Dejonker Owner - Owner's Name - - - information is required for every Barnstable Ma 02668 8/21/15 page City/Town - State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return - - key. Name of Inspector DiBuono Sewer and Drain rae_ Company Name -- 8 Johns path Company Address — - - °wr,—_— S Yarmouth MA 02664 City/Town State Zip Code 508 364 9587 S113522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation b Local Approving Authority Inspector's Signature 8/22/15 - - - Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""}This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. I CSL i5-S•3113 Eo V T lle.5 Official Inspection Form Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts „Vlr = Title 5 Official Inspection Form rI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1990 Main st/ Rt 6A - _ - Property Address Debra A Dejonker Owner Owner's Name information is required for every Barnstable Ma 02668 8/21/15 page City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system contains a 1500 gallon tank as well as 2 large leaching pits made of block. System is in good working condition B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "'no" or "not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old' or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will ,pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ms 3113 Tale 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 1990 Main st/ Rt 6A Property Address Debra A Dejonker Owner Owner's Name information is required for every Barnstable Ma 02668 8/21/15 _.._._ page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) ❑ 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 r� Title 5 Official Inspection Form X.- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1990 Main st/ Rt 6A - - Property Address -- - Debra A Dejonker Owner's Owner Name - - - -- -- information is required for every Barnstable Ma 02668 8/21/15 page City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance. " This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '12 day flow Tale 5 Official Inspection Form Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts � —IA Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1990 Main st/ Rt 6A Property Address Debra A Dejonker Owner _ Owner's Name information.is required for every Barnstable Ma 02668 8/21/15 page City/Town State Zip Code Date of Inspection B. Certification (cont.) — Yes No ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. f 5,ns•3113 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form I:.j Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1990 Main st/ Rt 6A Property Address Debra A Dejonker Owner Owner's Name _. information is required for every Barnstable Ma 02668 8/21/15 _. page. City/Town -- _ _ State Zip Code Date of Inspection C. Checklist - Check if the following have been done. You must indicate "yes" or"no" as to each of the following Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms desi n : 4 ( 9 ) Number of bedrooms (actual): 4- - DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440 II 15ins•3113 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form p Subsurface Sewage Disposal System Form - Not for Voluntary Assessments •/ 1990 Main st/ Rt 6_A Property Address Debra A Dejonker Owner - -- Owner's Name - — -- - - information is required for every Barnstable Ma 02668 _ 8/21/15 page. City/Town State Zip Code Date of Inspection D. System Information-------------------- --- ---------- Description: The system contains a 1500 gallon tank as well as 2 large leaching pits made of block. System is in good working condition. Number of current residents: _._ Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): 168 Gpd Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): ------- Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: _ 15,ns 3/13 Tale 5 Official Inspeciion Form Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ; _ it Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1990 Main st/ Rt 6A Property Address -- --- --- Debra A Dejonker Owner _ _.._. . . Owners Name information is required for every Barnstable Ma 02668 8/21/15 _— - page. Ity/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use Date Other (describe below): General Information Pumping Records: Source of information: None Provided Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: ------ gallons How was quantity pumped determined? -- ----------------.--__.__.__ _ Reason for pumping: Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ® Overflow cesspool ❑ 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): 15ins•3113 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 r - 1990 Main st/ Rt 6A Property Address Debra A Dejonker Owner _.. - Owner's Name —________---------------- ----- information is required for every Barnstable Ma 02668 8/21/15 page. City/Town - State _ Zip Code Date of Inspection D. System Information (cost.) Approximate age of all components, date installed (if known) and source of information: Tank appears to be Approximately 20 years Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer (locate on site plan): Depth below grade: 18" feet Material of construction: ❑ cast iron ❑ 40 PVC ❑ other (explain): - Distance from private water supply well or suction line: - - - -----..-._.-__ fee t --- - Comments (on condition of joints, venting, evidence of leakage, etc.): System is vented throught the roof. Septic Tank (locate on site plan): Depth below grade: 1 ft feet Material of construction: ® concrete ❑ metal ❑ fiberglass 9 El polyethylene ❑ other (explain) 1500 gallon If tank is metal, list age: years Is age confirmed,by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Gallon Sludge depth: 3" i5ins•3/13 Title 5 Official inspection Form Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts 471 C Title 5 Official Inspection Form •=' i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1990 Main st/ Rt 6A Property Address ----------- Debra A Deionker Owner — information is Owner's Name required for every Barnstable Ma 02668 8/21/15 page City/Town _ ------ - -----.__-- State Zip Code Date of Inspection Q. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 24 Scum thickness T' Distance from top of scum to top of outlet tee or baffle 42- Distance from bottom of scum to bottom of outlet tee or baffle 1" Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): No evidence of Ieaking,Tees and or baffles in place at time of inspection. Grease Trap (locate on site plan): Depth below grade: NA feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass 9 El polyethylene El 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 15.ns•3113 Tale 5 Official Inspection Form Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage ge Disposal System Form Not for Voluntary Assessments -/ 1990_Main st/ Rt 6A Properly Address Debra A Dej— onker Owner -- — wner--s---hame- -- ---. . ___.__ _.-----------.—_.—_-- information is required for every Barnstable Ma 02668 8/21/15 page. City/Town Co- - 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.): Tees are in-place and levels are normal. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: --_-- Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: - _ -- -- - -- - ---- - ---- - Capacity: - -.. gallons Design Flow: gallons per day -- -- Alarm present: ❑ Yes ❑ No Alarm level: ----- - --- - - Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No 15,ns•3113 1 tie 5 Official Inspection Form Subsurface Sewage Disposal System•Page 1 1 or 17 ` Commonwealth of Massachusetts a _ I Title 5 Official Inspection Form ' {'! Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1990 Main st/ Rt 6A Property Address - -- Debra A Dejonker Owner -- --- .. - - -- -Owner's Name information is required for every Barnstable Ma 02668 8/21115 page. City/Town a ---------- --- ------ ---- - --- -- —_ _ 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 Na Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 151ns•3113 1 de 5 Official Inspection Form Subsurface Sewage Disposal System•Page 12 of 17 i Commonwealth of Massa i chusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1990 Main st/ Rt 6A Property Address — — Debra A Dejonker Owner --------___---- - Owner's Name -- - ----- information is required for every Barnstable Ma 02668 8/21/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ----- - --.- ❑ leaching chambers number: - ------_---- ❑ leaching galleries number: ---- ----- -----. ❑ leaching trenches number, length: -- -- - ------ ❑ leaching fields number, dimensions: - - - - - ® overflow cesspool number: 2 ❑ 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.): No signs of carry over and no signs of hydraulic failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 2 in a line Depth - top of liquid to inlet invert second is dry Depth of solids layer Depth of scum layer _ Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/1 3 ritle 5 Official Inspection Form Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Is! Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a : 1990 Main st/ Rt 6A Property Address - - ---- - Debra A Dejonker Owner Owner's Name - -information is required for every Barnstable Ma 02668 8/21/15 page. City/Town -- _---- p 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 ): No signs of ponding or hydraulic failure. 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.): i5,ns•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 14 of 17 i Commonwealth<� alth of Massachusetts ,aV, --r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1990 Main st/ Rt 6A Property Address - Debra A Dejonker caner a Ow s Nme information is required for every Barnstable Ma 02668 8/21/15 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 t 5,ns•3/13 T tie 5 Official Inspection Form Subsurface Sewage Disposal System•Page 15 of 17 . T. rlt+t ar +.IY SI k7•, ,.!Jadw tly r-"zf�, l J. -,y J {' 4j �'✓ s•17,u .L x 4� h-I i I. ;L'r e -f 4 v 41+ Ir i} ti r -, 'L '+ .,r 3J A.f M `F'�t U! ,k!1 sr/J•r""' .+4n{a'i 4+,rj, J�}"Yt r:.. l wn��'1�.R1t�.�'1 r.�, r lnl M +, .t+ F jsV Sy !rC .w'.I e 4q �":,�? i -i � l �.�'ppC1y 7✓+ r4+ r+U*'trw� R .,�.,r 1::9},.J 1>r 1nn'Ls.�{'''.id .r i r I,. �,9ni w.a 16.t r d'.�Yak. .. t I :-,*4 K r I _ \,_y KytTf,� YIJ .t'xL-h'�j .Taffy f�4i S"1.1i,[[[,ttt1, + 1'11T'•.y�•' I�.r �,`ry{.fix�•.7 ,�`ti!'ift_�ri41! y r..�Y S t. 5 'I.It rV Tf �r {Y + ,� ;rt, r,-,�=k �. 1,b�,"-"ii,ti'k '`e'de:,y��M''S r :N ti; J4:i� �ry�S= 1ry'�1..�1'O1tj,Y�r?Ati ,aT i A)(^a/',:1+:.� r•r lti.! s rr°6 7 ,R'4 9�Iw'fif-i`ll t w"��" 1 i�':�.yµ r}N {} s .�»./ k .4i'�°(Y.IP �i, '{ 1 'iIl'�4 �`.'� D l �t��,�•eJl..ry. 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'"I t ',P'r 1 .-}i� 1 J F ti y.�r �J 4 -r + Y h t 1 l t ,r r u y ..- _l.,"r_ i- .L^....>. .:..._^...f .Lo? . ,•1.".: .....1.r- c. ..r ...- -.. - !_.._... 'L'J,.-- .. ..._/-.. .-1 .,.o-....+..,_. Commonwealth alth of Massachusetts Title 5 Official a Inspection Form Isl Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1990 Main st/ Rt 6A Property Address Owner - Debra A Dejonker - -- - -- - - -- information is Owner's Name required for every Barnstable Ma 02668 8/21/15 page City/Town — — State Zip Code Date of Inspection D. System Information (cont.) Site Exam: © Check Slope ® Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12+ ft 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: -... Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Test hole data see attached Before filing this Inspection Report, please see Report Completeness Checklist on next page. 151ns•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 1990 Main st/ Rt 6A Property Address - - Debra A Dejonker Owner -- Owner's Name information is required for every Barnstable Ma 02668 8/21/15 page City/Town Zip--- -- - 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 15,ns•3n3 llue 5 Official Inspection Form Subsurface Sewage Disposal System•Page 17 of 17 . ss t ant,fog Se)oak Disposal WORM .11�I04 L Spa 21��f ski( 7 su&=scones ft Wtt.ATM R, Drtikins.Water.Wen #� Umctt ortra 8 �; e tf�c ac►c s or rest ttOu.-s&.pace e�zc eon nrk in pcnnrmty to hobos O O O D T rk =, ¢,.. .r IMASON&L131G$W Tl TABi E . 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YCi;�.+N..S-� � r ��.....".....,.,�.....I ','-m�.n+.w:.e:m..v..�.:. .inu'�nrr:�e•`t+Y+.t�rxa ea�w!+✓ � I1s+d' �-•awn, v'`. ..�+fr':�rr"..•ra...c�....:.,.t.��wa..�,v.',-" with Qvs;i: i1 -0 im 40 ...a ...�. :- . .-: .:� R LOB Ito DoA Sail Tboc aairoso :Sclotl. ` �!a..,��riw�a rw•AI�1lwP�w I �.� P.�MYaPaMM�..�s.vsuW � ' i• Abort 9Qt?Ycar hied bouaida ►; N,o yraa, Town of Barnstable Barnstable s �ca�Re Regulatory Services Department satrKASS,t e 1619�- ,�' Public Health Division m 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO December 1, 2009 Dana Berry Debra Dejonker-Berry 1990 Main Street West Barnstable, MA The septic repair order dated November 9, 2009 for the septic system located at 1990 Main Street, West Barnstable has been retracted. After reviewing the inspection report submitted by David B. Mason, a certified septic inspector for the State of Massachusetts, it has been determined that the system"Passed" under the guidelines of 1995 TITLE 5 (310 CMR 15.00). t PER ORDER OF THE BOARD OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health op� (0/o'T Dt ixc. Barnstable Town of Barnstable Aa Regulatory Services Department Oft`edea j b F � ' Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 70081830000205009984 4/14/2009 Helen Corsa 1990 Main Street West Barnstable, MA 02668 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 1990 Main Street West Barnstable,MA was last inspected on August 23 2008,by Mark Polselli, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Failed" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: 0 Any portion of the SAS, cesspool, or privy below high groundwater elevation. You are ordered to repair or replace the septic system within One (1) year from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health Lb Q�7 0uVVq1_s 61oc) d s w 4� P^L r 1S.f M4 56 g , - 2ci 21 °7 re four 5� ®P',� ��qw� � Barnstable Town of Barnstable A#-Am&1ciC1ht ' ,�?3 Jam., Regulatory Services Department RARNSTABLF. K 1�vr s MASS.9. Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: >08-862-4644 Thomas P.Gciler,Director FAX: s08-790-6304 Thomas A.Mclean,CHO I� 11/09/09 Dana Berry Debra Dejonker-Berry 1,990 Main Street--- West Barnstable, MA FINAL ORDER ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at, 1990 Main St. West Barnstable, was last inspected on 08/23/08,by Mark Polselli a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Failed" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: "Tank appears structurally sound. Invert's not visible. Bottom of cesspool 9.4 below grade. House has sump pump, SAS is below high groundwater- automatic failure" The deadline for repair 8/23/09 has past. We, The Department of the Board o:f Heal.th, have not been informed that you have taken any steps to bring your failed system into compliance. Therefore, you are ordered to repair or replace the septic system within 60 days from the date you receive this notification. You may request a hearing before the Board of Health, a written petition requesting a hearing on the matter, within seven(7) days after the day this order was received. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. (acKean, R OF THE BOAR OF HEALTH K.S., CHO Agent of the Board of Health I ' COTYCOMMONWEALTH of MASSAGHUSEPI'S F.gECuim OFFICE OF PNviRoN1VIENTAL AFFAIRS r DEPARTMENT OF EN moNMENTAL PROTECTION y David B.Mason,R.S,Certified Title V Inspector,5084W-2177 TITLE 5 OFFICIAL INSPECTION FORM-. NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 1990 Route 6A,W.Bay astable,MA Owner's:Relen Corsa Owner's Address:Same Date of Inspection:October 16,2008 Name of Inspector:(please print)David B.Mason Company Name:-N.A. Mailing Address:4 Glacier Path East Sandwicb,MA 02537 Telephone Number:508-833-2177 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 Sib�natu . ate: D 11,6 12600 The system inspector shalt 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 Wd or greater,the inspector and the system owner shall submit die report to the appropriate regional offce.of the DEP.The original should be seat to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments:System as inspected is operational. Increase in occupancy may result in failure. Tank needs maintenance pumping.The information as identified represents only the condition of the system on October 16, 2008 at 10 AM:00 AM. This inspection does not a guarantee of the useful life of the septic system or its components,but only represents the condition noted at the time of inspection. The re-inspection has been submitted to represent change in information determined by the previous inspector,Mark Poselli on report dated 8/2312008, which failed the system due to assumed groundwater elevation. This inspector verified ground water as witnessed by the Town of Barnstable OFFICLA L INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Title 5 Inspection Form 6/15/2000 page 1 f Page 2 of 11 PART A CERTIFICATION (continued) Property Address: 1990 Route 6A,W.Barnstable,MA Owner's:Helen Corsa Date of Inspection:October 16,2008 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 CViR 15304 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`5zot detmmined"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 leafing 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 Healthy broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced (THIS IS REQUIRED TO BE COMPLETED) 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_ OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) 'Ntta S Tncry r•rinn From FJi 5/?CM 2 Page 3 of I 1 Property Address= 1"0 Route 6A,W_Barnstable,MA Owner's:Helen Corsa Date of Inspection:October 16,ZW8 C. Further Evaluation is Required by the Board of Health: Conditions exist which require fiuther evaluation by the Board of Health m 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 with310 CMR 15.303(1)(h)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 suipply. The system has a septic tank and SAS and the SAS is within a Zane 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 welly*.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: OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Titio 4 Tnenart.nn Pn ivi rnnnn 3 I Page 4 of 11 PART A CERTMCATTON(continued) Property Address:1990 Route 6.A,w_Barnstable,MA Owner's:Helen Corsa Date of Inspection:October 16,2008 D. System Failure Criteta 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 of luent to the surface of the ground or surface waters due to an overlooaded or clogged SAS or cesspool X Static liquid level m 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'/z 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 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 dean 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.IThis.system passes if the well water analysis, performed at a DEP certified laboratory,for cohfornat 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.l NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CM.R 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 o€10,000 gpd to 15,000 gPCL 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 su€fice drinking water supply _ the system is located m a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone H 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 15304.The system owner should contact the appropriate regional office of the Department. Titlo S lnrnPrt;nn Fnrm rvi Snnnn 4 Page 5 o€11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:1990 Route 6A,W.Barnstable,MA Owner's:Helen Corsa Date of Inspection:October 16,2008 Check if the fallowing leave been done.You must indicate`des"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 NIA) 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 bates 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 15302(3)(b)] OFFICIAL LNSPEC nON FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Title S 7nc»artinn P^rnn All,;nnno . 5 i Page 6 of I I PART C SYSTEM INFORMATION Property Address: 1990 Route 6A,W.Barnstable,MA Owner's:Helen Corsa Date of Inspection:October 16,2008 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):4(per assessors records)Number of bedrooms(actual):4 septic design DESIGN Sow based on 310 CMR 15.203(for example: 110 gpd x##of bedrooms):(440 gpd capacity) Number of current residents:_1 Does residence have a garbage grinder(yes or no):NO(Not Allowed) is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required]Per owner Laundry system inspected(yes or no):NA Seasonal use:(yes or no):NO Water meter readings,if available(last 2 years usage(gpd)): Property is serviced by Private Well. Sump pump(yes or no):No Last date of occupancy.current CONEVFERCIAL/INDUSTRIAL Type of establishment: . Design flow(based on 310 CMR 15203): gpd Basis of design Sow(seats/persons/sgf,etc_): Grease trap present(yes or no): Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Tide 5 system(yes or no): Water meter readings,,if available: Last date ofoccupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of infrmation: 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: Maintenance pumping is recommended. TYPE OF SYSTEM _X Septic tank,distribution box,soil absorption system —Single cesspool Overflow cesspool _ivy 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):no 0 i;t1a Tncrar tine Fnrm r,�t s»nnn 6 i Page 7 of 1 I OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1990 Route 6A,W.Barnstable,MA Owner's:Helen Corsa Date of Inspection:October 16,2008 BUILDING SEWER(locate on site plan) Depth below Bade:Approximate;62 Inches Materials of construction:_X_cast iron _40 PVC_other(explains mixed with orangeburg Distance from private water supply well or suction line: NA Comments(on condition of joints,venting,evidence of leakage,etc.):unable to observe without excavation. SEPTIC TANK:N.A.(locate on site plan) Depth below grade:56" 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: Typical 1000 gallon tank Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle-29" Scum thickness:0 inches Distance from top of scum to top of outlet tee or baffle:NA Distance from bottom of scum to bottom of outlet tee or baffle:NA How were dimensions determined: Actual measurements with tape and scour stick Condition of tank(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.) Tank appears structurally sound. No appearance of leakage. GREASE TRAP: N.A. Depth below grade:— Material of construction concrete metal - fiberglass—paiyel3rylene other (plain): — — Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffie: 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 bathe condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): M TiAA S Tncn,-Mt r%n Pn—n r1fl V?(w 7 i Page 8 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY,ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 19"Route 6A,W.Barnstable,MA Owner's:Helen Corsa Date of Iuspertion:October 16, 2008 TIGHT or HOLDING TANK: N-A_(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(expWn): 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: Not Present (if present must be opened)(locate on site plan) Depth of liquid level even with outlet invert liquid level even with outlet pipe Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM T+fiiP S incrrt;.,r,�`nrrn FJ]SL�flfld) 8 Page 9 of I I PART C SYSTEM ENFORMATTON(continued) Property Address: 1990 Route 6A,W.Barnstable,MA Owner's:Helen Corsa Date of Inspection:October 16,2008 SOIL ABSORPTION SYSTIE M(SAS): X (locate on site plan,excavation not required) If SAS not located explain why. Type leaching pits,number _Ieaciing chambers,number: leading galleries,number. Ieaching 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 ofponding,damp soil,condition of vegetation, etch CESSPOOLS: X (cesspool must be pumped as part of inq=tion)(locate on site plan) Number and configuration:2 in series. Unit#1 was dry and Unit#2 was not opened. Depth—top of liquid to inlet invert Dry with staining indicated to invert outlet in Unit 41 Depth of solids layer NA Depth of scum layer_NA Dimensions of cesspool:b x 6 Materials of construction:block Indication of groundwater inflow(yes or no):No.See attached soil report with ground water in€o. Comments(note condition of soil,signs of hydraulic Wb re,level of ponding,condition of vegetation.,etc.): No indication of hydraulic failure. Unit#1 has historical staining to outlet invert PRIVY:_N.A_(locate on site plan) Materials of construction: Dimensions: Depth ofsolids- Comments(note condition of soil,signs of hydraulic failure,level of pondiag,condition of vegetation,etc.): r;�tp S uscrv+rti.�n Fnrsn uu snnnn 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1990 Route 6A,W.Barnstable,MA Owner's:Helen Corsa Date of Inspection:October 16;2W8 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposzl 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. Well location per property owner. Location as indicated is FRONT . 100'from SAS A B Septic Tank 1 2 A-1 26' . ❑ B-1 44' A-2 26' B-2 39' . OP. Leach Pit A-3 72' B-3 66' OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM `tiNP S dnen t4nn Fnrm A!1 S/7l)Ill1 l� i i Page 11 of 11 PART C SYSTEM INFORMATION(continued) Property Address: 1990 Route 6A,W.Barnstable,MA Owner's:Helen Corsa Date of Inspection:October 16,2008 SITE EXAM Slope Suurface water Check cellar (crawl space) Shallow wells Estimated depth to ground water 20 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: _X Observed site(abutting propertylobservation hole within 150 feet of SAS) X_Checked with local Board of Health-explain:Recent Test Holes. Existing engineer records with BOH X Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Utilized the Town of Barnstable Groundwater Contour Map. Conducted a soil analysis witnessed by David Stanton of the Barnstable Health Department. No ground water was encountered to a witnessed depth of 159". See attached soil log. T+taa S Tncnr+rtinn Fnxm (.�15/7(lEl(1 11 :I I Town of Barnstable P# ji Depabiment of Regulatory Services Public Health Division Date " trues 200,Main Street.Hyannis MA 02601 n: I / t.i Date Scheduled :J 1`! ' Tune Fee Pd —" Soil Suitability Assessment fox Sewage Disposal. �►4A�t�7 1,t1tO 'Pettmmed By: Wimetsed By: LO ATiON&VENERAL W-01 A /� Z/1 Location Address pU Owitet s Name (�1 L�J Addressl AssessoesMap/Paicek C�1 ( V!5 Saea's �Q1�ex 7Uy)�bU4 NEW CONSMUCITON REPAIR `h7J Telephone#eDF, Land Use - Slopes(To) - Surface Stones Dnmaces Sam: Open Water Body .. ft PossIbIe Wet Amu ft Drinking Water WeO ft Dmiaage Way ft Property time ft Other A SKETCH:(S4xt name,dimensions of kt.exact locarions of test holes&per=tests j'—wetlands in ptoodimty to holes) F N 0 4 f C n cn v: i F- M. C Parent mazcid(geologic) O t* Depth to Bedrock '. t o 0 Depth to Oroundwater.Stang water in Hole { � ing from Pit Face Estimated SeasonaI High Groundwow RMINATION FOR SEASONAL HIGH WATER TABLE Method Used : Depth Observed shndmg in obs hole bh Depth to.soil MoUW9 in Depthmweepingimmsideofobs.hone iq Cl�tmdwnterAt(tttstm®t om iz Index Wefl# Readmg Date . IndaS Weil Ievdl ..,; AaL thttorm-Ad(.dwondw0W Levt1,,,,0. PERCOLATION TEST Thna ozsetvaHw . ... _ Holeffi. 'fSme u 9°' Depth of Pere Tnae ai r S[artPte-soak TimeCd 't�me(9"-6'7 Pad Pre-soak Rate Nfin rt.Mh Site Sattabi&y Assessment: Site Pasted Sire Rated Add¢ionat Tesaug Needed(Y/M prigml:Public Health Dimon Observation Hble Data To Be Completed on Back *—If percolation test is to be conducted vdthin 1OW of wefland,you mast first notify the Barnstable Conservation Division at least one.(1)week prior to beginning. Q ISBrI WERUORM-00C DEEP.OBSERVATION HOLE DOG Hole# Ikpth from Sok Hod= Sal Texh- .sota Color soil. Other Sasface fm) (MDA). Mottling (Strugme,Swum.Boaldem Hw t0 La V-171D C L�l Z, b DEEP OBSERVATION HOLE LOG Hole.# Dcpthfrom SoilHaizoa SoaaTezhat Sort dolor SOH Other Surfax fm) (USDA} (Muuxli) Mottrmg (Stmaroe.Scorns.Bonldm- Val/ DEEP OBSERVATION HOLE LOG Hole# pepth¢ara SouHorizou soiITcmm Soft COW Sort Other S=ffi=Cra) (USDA) (Idmscl►3 Moarmg (Stracttac,Stones,Boulders. DEEP OBSERVATION HOLE LOG Hole# Depth from soa nod= SGHText= Son OAur soft Other Surface Cm.) (USDA) EMS) ' Mottrmg mmc- rc.Stores,Boutdas. i Flood iffiaranCe Rate Magi Above 5ooyearfloodbo®dary No� Yes Vubi.Soo yeoun ar boundary Na Yes,: .r . With;aiG',year:' > "-No✓ _..Y�.„� Depth of NaMU Occur-riia¢Pons Material exist in all areas obsen+ed throughout the Does at least four feet of w6ally ocauriing pervt area Proposed for the soil.absorptibn system? ,A if not what is the depth of- occtii ing pervious material? Certification approved by I certify that on (datt;)I havepassed the soil evaluator examination appra the Department of laviroAmeaaal Protection and that the above analysis was perforated y me tit with . the te4�trai�g, described in 310 t'1viR IS.Qi7. Signature Date Ib l Q:ISppi�tGlpg&CFORMMOC i p . COMMONWEALTH OF MASSACHUSETTS w EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION f � O 51 5150 TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: / / go ' M h sr, ,+�r eS+ OJ669 Owner's Name: Hetev7 f'''fA Owner's Address: ¢ O 4 /¢ l s . Date of Inspection: OD Name of Inspector: lease print) " a,4- / .'Ire'll/ J �' Company Name: lYl//Q —%�G�/ cis` Mailing Address: O aox /dam Telephone Number oS " uo 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: Passes Conditionally Passes Needs-Turther Evaluation by the Local Approving Authority Fails Inspector's Signature: OaX Date: O-51 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. 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 p CERTIF,IQC.ATION(continued) Property Address: / /0 Owner: C.r✓'S'C, Date of Inspection: 0 LO? 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 CNIR 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 v4ll 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)i611 pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESS'IENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CCERTIFICATION(continued) QQ Property Address: / 7 o 1� Owner: O,rs Date of Inspection: 0�3 C. Further Evaluation is Required by the Board of Health: A/ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(i)(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 FO1;UAT PART A CERTIFICATION(continued) Property Address: lyio r �A OOL46f Owner: / Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or �-<ogged SAS or cesspool _ v Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or _ cesspool T,4quid 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 a er supply. portion of a cesspool or privy is within a Zone 1 of a public well. 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 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—BVPA) 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 C-MR 15.304. The system owner should 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 `I CHECCKLIST Property Address: V // Owner: O✓ Date of Inspection: g o 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 he system received normal flows in the previous two week period? Have large volumes of water been introduced to the system stem recently or as part of this inspection? _ g ere as built plans of the system obtained and examined?(If they were not available note as NIA) _ Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for simians of break out? Were all system components,excluding the SAS,located on site? Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes n(L� E i ing 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: 1270 Owner: 4r Date of Inspection: o� FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual):T DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): T�V Number of current residents: 0 Does residence have a garbage grinder(yes or no):/-O Is laundry on a separate sewage system yes or no):O [if yes separate inspection required] Laundry system inspected(yes,or no): Seasonal use: (yes or no): Water meter readings, if a ailab�(last 2 years usage(gpd)): Sump pump(yes or no): , Last date of occupancy: C ONIMERC IAL/IND U S TRIAL 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/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspec on(yes or no): If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pum ing: TYP F SYSTEM _ eptic tank, distribution box soil absorption system CL--: sS' 00/ _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 kn m)and source of information: Were sewage odors detected when arriving at the site(yes or no)&O Page7of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Q Owner: Date of Inspection: BUILDING SEWER(locate n s.te plan) Depth below grade: ((pp//�' / Materials of construction: ast iron _40 PVC_other(explain): © G► Vt ye' Distance from private water supply well or suction line: Comments(on condition.of joints,venting,evidence of leakage, etc.): (/ , SEPTIC TANK._(locate on site plan) f—n: �� Depth below grade: Material of constructi _ oncrete_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: Sludge depth: 4 Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 0 _ Distance from top of scum to top of outlet tee or baffle: SG.0 Distance from bottom of scum to botto}}q�offutl t tee or baffle: How were dimensions determined: (Y/o e Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as re ted to outlet invert, evidence of leakage,etc.): / n ✓I o 2ac�e Cc 4- a H Cr w nv2v s IfIcrt t'%-r 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 inteariry, 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: / 90 Ps fah -J.6� � �9 4�cr� Owner- Date Date of Inspection: TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes.or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:�if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box, etc.): PUMP CHAMBER:�(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.): 'r:a,, c T t: r c i c»nnn 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART C SYSTEM INFORMATION(continued) Property Address: Mb 9� 64y��/ Owner: ��✓ C' Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): y(locate on site plan,excavation not required) If SAS not located explain why: Type 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 ponding,damp soil, condition of vegetation, etc.): CESSPOOLS: (cesspool must be pumped as part of' spection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: -e w Depth of scum layer: Dimensions of cesspool: Materials of construction: oc Indication of groundwater inflow(yes or n t� w►� ��Py Co ents(no)e condition of soil,signs hydraulic failure,level of ponding,condition of vegetation;etc.): c.�n{ � o 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 ASSESSINIENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Y90 Owner: C�I�JI G/'v►,�-u�[t�. Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including t st two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.Lo w re public wa r supply enters the building. EL V ��0✓i 7 W Epps � a I v�ve�•a-s yl 1 �'3 3 10 I s Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOWN1 PART C Q(� SYSTEM INFORMATION(continued) Property Address: / 7 0 �Owner: CO 11 Date of Inspection: JA SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 2 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 descri ho you established g i h rprid water el vation: g CQjf oo ((7�✓ �ia s p L-