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HomeMy WebLinkAbout0144 MEADOW LANE - Health 144 Meadow Lane West Barnstable A= 133-026 L� �I I 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Dis I System Form-Not bpWbUntary Assessments 144 Meadow Ln.West Barstabte, MA 02668. eCern 1 Property Address Richard Prout Owner Owner's Name information,,; a osprey FL 34229 4/17/2015 �= page. City/Town State Zip Code Date of Inspection w s?`7 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. h When A General Information filling out 3 out forms on the computer, use°nry the tab 1. Inspector key to move your cursor-do not Paul Martin use the return Name of Inspector key. Cape Cod Septic Services _1� Company Name 350 Main St Company Address W.Yarmouth MA 02673 City/Town state Zip Code 508-844-6195 S15016 Telephone Number License Number B. Certification I certify that 1 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(MO CMR 15.000).The system: 0 Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 4/26/2015 nspectoes Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. if the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in a future under the same or different conditions of use. y f5ins•3I73 Title 5 Orficrg hWecbm Form:Subsaface sewage DWposai S •Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 144 Meadow Ln.West Barnstable, MA 02668 Property Address Richard Prout Owner Ownees Name infonna6on isOsprey FL 34229 _ 4/17/2015 Pap--refit far every Ckyrr� State ZipCode Date of Ir>specdW B. Certification (cost.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist Any failure criteria not evaluated are indicated below. Comments: System in working condition ---- 13) 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 exf'Itration 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 Cerlifca a of Compliance indicating-that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5hs•W Title 5 Offidal WzpeWM Form:Subswfaw Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 144 Meadow Ln.West Barnstable, MA 02668 Property Address Richard Prout Owner Owner's Name inform is Osprey FL 34229 4/17/2015 required for every City/Town state Zip Code Date of inspection Paw. B. Certification (cons.) ❑ Pump Chamber pumpstalarms 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 t5ft•3M3 Title 5 Official kWecbm Form:SubsLoface Sewage Disposal System•Page 3 of V Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 144 Meadow Ln.West Barnstable, MA 02668 Property Address Richard Prout owner Owner's Name information is Osprey FL page- �y�� Zip 4/17/2015 required for every State Code. Date of InspecOon Page 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 aseptic 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 coldbrm 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 ropy 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 dogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than Y2 day flow t5ins•3N3 Title 5 of cim kmpectton Form:SLbsaface Sewage Disposal System•Page 4 or 17 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Fonn-Not for Voluntary Assessments 144 Meadow Ln.West Barnstable, MA 02668 Property Address Richard Prout owner Owner's Name iWormatron is Osprey FL 34229 4/17/2015 required �y forevery /Town state Zip Code gate of crisped page. B. Certification (cunt.) Yes No ❑ ID Required pumping more than 4 times in the last year NOT due to dogged 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 coliforn 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.] El ® 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"rW 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 Fi 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 shalt upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5kis-W TM 5 Offiaaf kspecbm F"m Sftsraoe Sewage Dispose System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 144 Meadow Ln.West Barnstable, MA 02668 Property Address Richard Prout Owner ownets Name ifflormatior1 is Osprey FL 34229 4/17/2015 required for every page- Cityr,own State ZipCode Dam 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, looted 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. ❑ 0 Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System. Information Residential Flow Conditions: Number of bedrooms(design): Unknown Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): WA t5k*-3M 3 Title 5 offidW Impaction Form Sbmefaoe SmW Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal.System Form-Not for Voluntary Assessments 144 Meadow Ln.West Barnstable, MA 02668 Property Address Richard Prout Owner Owner's Name inquh,ed fd osprey FL 34229 4/17/2015 required for every frown State Zip Code Date of Inspection page. �Y D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system?(include laundry system inspection ❑ Yes No information in this report) Laundry system inspected? ® Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available(last 2 years usage(9Id)): Detail: Sump pump? ( Yes No Last date of occupancy: Un own Commerciabllndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons Per day(pd) Basis of design flow(seats/personslo.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: f o-3f13 rtft 5 oftial hVeaion Form&bwiaoe Sewage SysWm•Page of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments 144 Meadow Ln.West Bamstable, MA 02668 Property Address Richard Prout Owner Owners Name irdOffnatiO°is Osprey FL 34229 4/17/2015 required for every ciiylTown StaUe Code Date of Inspection Page D. System Information (cunt.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: No Records Was system pumped as part of the inspection? ❑ Yes No If yes,volume pumped: galtons 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): tuns•3M3 Tita 5 OMCIW Wgpe Fomr.&kwface&"p Dispel System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 144 Meadow Ln.West Barnstable, MA 02668 Property Address Richard.Prout Owner Owner's Name kdoff ratio`r is Osprey FL 34229 4/17/2015 required for every Pap- Slate- citylrmn Zip Code Date of Fnspefion D. System Information (cons) Approximate age of all components,date installed(if known)and source of information: Est 25-30 years Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): r Depth below grade: feet Material of construction: ❑cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: +1 Q'feet Comments(on condition of joints,venting, evidence of leakage,etc.): Line checked with sewer camera and was found to be clean, property pitched with no sign of root intrusion. Septic Tank(locate on site plan): 6'2" Depth below grade: feet Material of construction: ®concrete ❑metal ❑fiberglass 0 polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1,250 5-8° Sludge depth: t5k s-3M 3 TWe 5 off=d heped m FWW Stburrace Sewage Disposal System-Pap 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments .' 144 Meadow Ln.West Barnstable, MA 02668 Property Address Richard Prout owner owner's Name kdorrnation is pm FL 34229 4/17/2015 required for every Rot n State Zip Code Dade of Inspection page- D. System Information (cont.) Septic Tank(cont) Distance from top of sludge to bottom of outlet tee or baffle 1-3" 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 Estimated 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.): 1,250 Gal H-10 tankk in good condition. PVC tees in place and dean.Tank at normal operating level. Covers I Z'below grade. Grease Trap(locate on site plan): Depth below grade: Let Material of construction: ❑concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date tSms•3113 Title 5 offictW hWecbon Form.Subs+irfaee Sewage o VOW SYstem'Page 10 Of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary.Assessments 144 Meadow Ln.West Barnstable, MA 02668 Property Address Richard Prout Owner Owner's Name rnforrnatiO°is Osprey FL 34229 4/17/2015 required for every Cityrrown State Zip Code Elate of inspeaim D. System Information (cont.) Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Capacity: gawns Design Flow: gal m W day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in wort"order: ❑ Yes ❑ No Date of last pumping: tare Comments(condition of alarm and float switches,etc.): *Attach copy of current pumping contract(required). is copy attached? ❑ Yes ❑ No t5bs•3113 Title 5 Ofaal trapaGion Form:Subwrrace Sewage Disposal System_-Page 11 or 17 CommonweaEth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 144 Meadow Ln.West Barnstable, MA 02668 Property Addtew Richard Prout Owner Owner's Name informations Osprey page FL 34229 4/17/2015 required for every Cityrrawn State Zip Code Date of Inspection per• D. System Information (cons) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No access to d-box as is under paved driveway. Box viewed with sewer camera and was found to be in good condition 1 line in and 2 lines out. 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: t5 ns-3/13 Title 5 offroal kq)emw Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusefts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 144 Meadow Ln.West Barnstable, MA 02668 Property Address Richard Prout Owner Owner's Name infi 'ter is Osprey FL 34229 4/17/2015 required for every page- Cdyrrown State Zip CodeDate of heron D. System information (cont.) Type: ® wing pits number. 2-6x5 ❑ leaching chambers number. ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovative/atternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil,condition of vegetation,etc.): 2-6x5 leach pits on this system in working condition.One pit dry with staining around 18". Second pit 6"of liquid with staining about 2' No sign of overloading or hydraulic failure. Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No 15iru•W3 Title 5 OMdal hspecUon Form Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 144 Meadow Ln.West Barnstable, MA 02668 Property Address Richard Prout Owner Owners Name information is Osprey FL 34229 4/17/2015 required for every page. City/Town state Zip Code Dafie of Inspection D. System Information (cunt.) 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.): t5ins•3/13 Title 5 Offidal hupecbm Form:Subwrface Seale Dim system•Pap 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 144 Meadow Ln.West Barnstable, MA 02668 Property Address Richard Prout Owner Owner's Name infdrMabOn is Osprey 34229 4/17/2015 required for every page. Cityfrown State Zip Code Date of inspection D. System Information (cunt.) 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 Beet. Locate where public water supply enters the building. Check one of the boxes below. i ❑ hand-sketch in the area below drawing attached separately t5im-W Title s Official heron Form:Sub�Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 144 Meadow Ln.West Barnstable, MA 02668 Property Address Richard Prout Owner Owner's inkrmation is required for every Osprey FL 34229 4/17/2015 Page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Site Exam: ® Check Slope ® Surface water ® Check cellar Shallow wells Estimated depth to high ground water. 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: installers❑ ins attach documentation Checked with local excavators, tat -( ) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ms•3M3 Tdje 5 of6aai hspec imt Form:Subsurface Sewage Disposal System'Page 16 of 17 -C\-' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System.Form-Not for Voluntary Assessments 144 Meadow Ln.West Barnstable, MA 02668 Property Address Richard Prout owner Owner's Name information equired for every Osprey FL 34229 4/1712015 required page. Citylroan State Zip Code Date of tnspedron E. Report Completeness Checklist ® Inspection Summary:A, B, C, D,or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3M3 rift 5 Official kispection Fomr&bgufaoe Sewage Disposal System•Page 17 of 17 .. t ommonweaaaan.oT masssacnusem Title 6 Official Inspection For - Subsurface Sevvac,�e Disposal System Form Not for Voluntary Assessments Owner irsor nation is requited for every �ace- Do SYSteM Information (cola.) Sketch of Sewage visposai System_ Provide a view 0-the sewage drsprsal sysie.rr, ir;vdrrg tiffs tc a:;east 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: fl hand-sketch in the area below Q drawing attached separately i 7 , o y �� I �7—z2 4 ti i I I , } Kns=09108 Title 5 Official inspection Form:Subsurface Sewage CRsposal System•Page 14 of 16 C\� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal (stem Form-Not f d(VU14fitaq,Assessments 144 Meadow Ln.West Barnstable,MA 02668 6tem 2 Property Address .w: Richard Prout owner owner's Name information is Osprey FL 34229 4/17/2015 required for every pap- cityrrown State Tap 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:�n A. General Information g 5to on the computer, use only the tab 1. Inspector: key to move your cursor-do not Paul Martin use the return Name of Inspector key. Cane Cod Septic Services - _ - ► Company Name 350 Main St Company Address W.Yarmouth MA 02673 Cityrrmn State Zip Code 508-844-6195 S15016 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 16.340 of Title 5(310 CMR 15.000).The system: 0 Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 4/26/2015 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. '"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. I5ko•W13 Title s officwt Fow SWw few Sewage Disposal S •Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 144 Meadow Ln West Barnstable, MA 02668 System 2 Property Address Richard Prout Owner Owner's Name information is Osprey page. Zip 34229 4/17/2015 pagrequired for every Cityrrown State Code Date of In on e. B. Certification (coot.) Inspection Summary:Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any infbrmation 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: Seem in 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 infiftration or exfiitradon 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): t5ft•3113 Title 5 onf=W trWecbon form:Subwbw Sewage Disposal System'Page 2 of 17 Commonwealth of Massachusetts Titre 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 144 Meadow Ln West Barnstable MA 02668 System 2 Property Address Richard Prout Owtef Owner's Flame information is Osprey FL 34229 4/17/2015 required for every page. �y�� state Zip Code Date of Inspection Page B. Certification (cost.) ❑ 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 ON ❑ 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 CUR 1&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-3f13 TAIe 5 offidat mspac im Fomc Subsucfaee Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 19.0 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 144 Meadow Ln West Barnstable, MA 02668 System 2 Property Address Richard Prout owner owner's Name information is Osprey FL 34229 4/17/2015 required for every page. City/Townstate Zip P Code Date of inspection B. Certification (cunt.) 2. System will fail unless the Board of Health(and Public Water Supplier,if any) determines thatthe system-is.functioning in a mannerthat..pratects 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. i 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 '/day flow 3n3 Time 5 O>ficial 9specbm Fonm Sbmrace Sewage Disposal System•Page 4 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 144 Meadow Ln West Barnstable, MA 02668 System 2 Property Address Richard Prout Owner Owner's Name infORnatiOn is requiOsprey FL 34229 4/17/2015 pne for every C�lTown Zip code Date of Inspection r�- B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to dogged 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 collform 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.t have determined that one or more of the above failure criteria east 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'Protec ion Area-IWPA)or a mapped Zone Il of a public water supply well If you have answered"yes°to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5ins-3113 rdia 5 OMCIW Inspection Form:Sbefaw Sewage Disposal System•Page 5 of W Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 144 Meadow Ln West Barnstable, MA 02668 System 2 Property Address Richard Prout owner Owner's Name '"fO""atiO°is Osprey FL 34229 4/17/2015 required for every page- ed-y-i own State Zip Cock Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or ane as to each of the following: Yes No ® E] Pumping information was provided by the owner,occupant, or Board of Health ❑ 0 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? 0 ❑ Were as built plans of the system obtained and examined?(if they were not available note as WA) ® ❑ 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 ® El information on the proper maintenance of subsurface sewage disposal systems. The sae and location of the Soil Absorption System(SAS)on the site has been determined based on: �{ ❑ Existing information. For example,a plan at the Board of Health. ❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): Unknown Number of bedrooms(actual): 1 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): WA t5ms•3r13 Tide 5 offaw mspechan Form:Subs<wftwe Sewer Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 144 Meadow Ln West Barnstable, MA 02668 System 2 Property Address Richard Prout owner Ownees Name informafim is Osprey 34229 4/17/2015 P Pap- City/Town State Zip Code Date of Inspection D. System Information Description: 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes 0 No Unknown Last date of occupancy: Date CommerciaUlndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Ga=pw day W) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins,3M3 Title 5 official bmpedm Form Sub%d we Sewage Did System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 144 Meadow Ln West Barnstable, MA 02668 System 2 Property Address Richard Prout owner owner's Name i"foffnatiOn is FL 34229 4/17/2015 required for every Osprey Pap cityrr"n State Zip Code Date of Inspection D. System Information (cant.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: No Records Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gaflons 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/Altemative 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 l/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5au.3r13 TfUe S Offida.hV8ction Form SUMulaee Sewage 0L9xsaJ System•Page 8 of 17 Commonwealth of Massachusetts Witte 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 144 Meadow Ln West Barnstable, MA 02668 System 2 Property Address Richard Prout Owner Owner's Name hrrormation is Osprey FL 34229 4/17/2015 required for every page. CityRown state Zip Code Date oinspedion D. System Information (cons) Approximate age of all components,date installed(if known)and source of information: 25-30 Years Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 3' Depth below grade: feet Material of construction: ❑cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: +10'feet Comments(on condition of joints, venting, evidence of leakage,etc.): Line checked with sewer camera and was foound to be clean, property pitched with no sign of root intrusion. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain) If tank is metal, list age: y"S Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: tSires•3M3 Idle 5 ofroal 9Wedim Fomr SbwstWe Sewage Dispo sat System•Page 9 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 144 Meadow Ln West Barnstable, MA 02668 System 2 Property Address Richard Prout owner Owners Name information is Osprey 34229 4/17/2015 required for every Page• Cityrrown state Zip Code Date of frrspeaion D. System Information (cont.) Septic Tank(cant) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to flop of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments(on pumping recommendations, inlet and outlet bee 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: Beet Material of construction: p concrete ❑ metal ❑fiberglass ❑polyethylene p 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 fast pumping: Date gins.3(13 Title 5 Official hWection Fanrc&b urace Sewage Dmpowd System•Page 10 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 144 Meadow Ln.West Barnstable, MA 02668 System 2 Property Address Richard Prout owner Ownees Name tfff°rnnat10"is required for every Osprey FL 34229 4/1712015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): 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: 9a*m per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working sec ❑ 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 t5ms•3N3 Title 5 Most loon Form:Substxraee Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 144 Meadow Ln.West Barnstable, MA 02668 System 2 Property Address Richard Prout Owner Owner's Warne information is Osprey FL 34229 4/17/2015 required for every page. Cityfrown 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 WA 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: ♦Sits.3M3 Tide 5 Of tidal fspaetion Forth:Subsuf6ce,Sewage Disposal System•Page 12 of47 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System form-Not for Voluntary Assessments 144 Meadow Ln.West Bamstable, MA 02668 System 2 Property Address Richard Prout Owner Owner's Name information is Osprey FL 34229 4/17/2015 regtdred for every Cityrrown State Zip Code Date of tnspedion iW- D. System Information (cost.) Type: ❑ leaching pits number. ❑ leaching chambers number. ❑ teaching 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.): Single Cesspool no overflow or leaching facility. Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration 1 Depth—top of liquid to inlet invert Dry Depth of solids layer N/A Depth of scum layer N/A Dimensions of cesspool 6x5 Materials of construction Precast concrete Indication of groundwater inflow ❑ Yes No t5ins.W3 Title 5 Official Mspeetion FomK Subs urace Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 144 Meadow Ln West Barnstable, MA 02668 System 2 Property Address Richard Prout Owner Owner's Name is req uired Osprey FL 34229 4/17/2015 rert e. for every OW TOM State Zip code Date of hrspec�On page. D. System information (cunt.) Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): 1-6x5 Precast leach pit acting as single cesspool. Pit dry at time of inspection with staining around 2$" No sign of overloading 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.): W 3 Title 5 Of dal Form:SLbmrlaoe Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ME Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1W 144 Meadow Ln.West Bamstable MA 02668 System 2 Property Address Richard Prout Owner Owner's Name information is Osprey FL 34229 4/17/2015 required for every p Y pa" Citylrown Stab: ZipCode 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 budding. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately -3113 Me 5 Officid hwection Form:Subsurface Sewage Disposal System•Page 15 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 144 Meadow Ln West Barnstable MA 02668 System 2 Property Address Richard Prout owner Owner's Name infortnatiof 1 is Osprey FL 34229 4/17I2015 requited for every page. Cfty/Town State Zip Code Date of lnspe t D. System Information (cons.) Site Exam: ® Check slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water. 16'+ 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 1.50 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain. You must describe how you established the high ground water elevation: Hand auger through bottom of dry pit on system 1 to 16 with no water encountered. Bottom of pit at 8`6". Minimum of 7`6"Separation. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t%W-3113 Title 5 offiael Fore 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 144 Meadow Ln.West Barnstable, MA 02668 System 2 Property Adder Richard Prout owner owner's Name requir required is re FL 34229 4/17/2015 required for every �a n page State Zip Code Date of trapedion 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 t5h*•313 Title 5 Official Form:&bs<sface Sever Disposal System•Page 17 of 17 t.,orn 3'i®S:weatvc8' or massc"cnusevs �a Title tidal Ins---ection Form Subsurface Sewage Disposal system Form -Not for Voluntary Assessments Owner iniarrnation is required for every Dace. De System Information (c-opt.) Stretch Of Sewage ©isposai System: ProWde a view Off the Stowage disposal system, irr fuding$'ws#o at least two permanent reference lands marks or benchmarks. Locate ail wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: p hand-sketch in the area below* ❑ drawing attached separately �I '� ;•� ice. „��' C er ' � . 4- 1-7 { I { ;Sins•09M Title 5 Offtaal Inspection Form Subsurface Sewege Ciaposa6System•Page 14 of 16 83 - COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS t% DEPARTMENT OF ENVIRONMENTAL PROTECTION f�E�Ei►�t I ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 v qpR 2 000 TOWjyOF `� ems" ��'�t$JDY C,(�\E v Secretary ARGEO PAUL CELLUCCI D��B' �'STRL S Governor +Comaussiorer SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: ( d,r1 Name of OwnerG� Lile� Address of Owner: ??� Date of Inspection. 10 6 0 Name of Inspector:(Please Print) LJXA. I am a DEP p%o ,,YLsystem inspector ursuarrt to Section 15.340 of Title 5(310 CMR 15.000) Company Name: r� ) Mailing Address: !iY/L�/1,,— Telephone Number: J CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes Needs Furth e Evaluation By the Local Approving Authority _ Fails Inspector's Signature: Date: u 4 The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty(30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner "shall submit the report to the appropriate regional office of the Department ot-Environmental Protection. The original should'be sent tovm system owner.and copies sent to the buyer, if applicable, and the approving authority. . NOTES AND COMMENTS revised 9/2/98 Page 1 of 11 A i.1 Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: (qq h'�u�� 4/eC J Own : 5 ' ' Lbw Date of Ins on: 3 // DU INSPECTION SUMMARY:: (Check A, B, C, Or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: L-rZ b-D o D B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached) indicating that the tank was installed within twenty (20)years prior to the date of the inspection; or the septic tank, whether or not metal,is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is-due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumpirfg-more than•fourtimes a year-due to broken or obstructed pipe(sl. Thesystem wKjra3r inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed revised 9/2/98 Page 2of11 Q v } SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: g L Owner: t✓ Date of Inspection: /,//j�j' C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE EN.VJHONMEHT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid).- 3) OTHER revised 9/2/98 Page3ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: A� Owner: fjiL Y Date of Inspection: 0 D. SYSTEM FAILS: 77 You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination Is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facili"r"stem component,due tto an overloaded orclogged•SASor•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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for -coliform bacteria, volatile organic-compounds, ammonia nitrogen-and nitrate nitrogen. - E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is-within 200 feet ofe-tfibutary•to a surf ace-drinking•water-supply •• •- - --- - - the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 11 of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4of11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owned I y Date of nspection: / �� Check if the following have been done:You must indicate either"Yes" or "No" as to each of the following: Yes No _ Pumping information was provided by the owner, occupant, or Board of Health. None of the system-components haua-been pua►ped4orat least two weeks and-the system hasbaaasaceNingeftmal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of.sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. _ All system components, stern, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on-the site has been determined based on:-- Existing information. For example, Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) (15.302(3)(b)] The facility owner(and.occupants,if differeat from.owner).,were.provided.with infaunatioaan Oia4uoppr rnaintenaoc"f SubSurface Disposal Systems. revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property tP Cress: !►`�" ^ �'_ owner: Date of Inspection: 3 FLOW CONDITIONS RESIDENTIAL: Design flow:�g.p.d./bedroom Number of bedrooms(desi n). 3 dumper of bedrooms(actual): Total DESIGN flow lTf Number of current Epsidents:_ Garbage grinder E s r no): Laundry(separatyes (yes or :_; It yes, separateinspection.required _ Laundry system inspected (yes or no) Seasonal use(yes or4s�_ Water meter readings,if available(last two year's usage(gpd): Sump Pump(yes or no):-�T� . Last date of occupancy: COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: gad ( Based on 15.203) Basis of design flow 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: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information- ' k4� 01,r/ry System pumped as part of inspection:(yes o n If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM _ Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records,If any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other Q APPROXIMATE AGE of all components, date installed{if known) •end source of•ipformation:�/f/•. /�U Sewage odors detected when-arriving at the site: (yes o no _ revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: / Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade:___ Material of construction:_cast iron_40 PVC_other(explain( Distance from private water supply well or suction line Diameter Comments: (condition of joints,venting,evidence of leakage,-etc.) SEPTIC TANK: (locate on site plan) Depth below grade:Material of construction:Xconcrete_metal_Fiberglass _Polyethylene_other(explain) fZ� rj If tank is (petal,list age_ Js.age.confirmed by Certificate of Compliance_(Yes/No) / oy � - Dimensions: Sludge depth: l -- Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: /& Distance from top of scum to top of outlet tee or baffle: Ze Distance from bottom of scum to bottom of outlet tee or baffle:_ How dimensions were determined: a/'14`11g' 0 Comments: (recommendation for pumping, condition of inlet and outlet tees or-baffles, depth of liquid level in relation to outlet invert, structuraFintegrity, evidence of leakage,etc.) 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: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) revised 9/2/98 Page 7orn SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: n �Own er: 5 tt�L Date of Inspection: 3lIq o TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or 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 Alarm level: Alarm in working order:Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX:_�C (locate on site plan) Depth of liquid level above outlet invert: Comments: (note-if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) — PUMP CHAMBER:_ (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.) revised 9/2/98 P2ge8Of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: (�/% 6Y`��v J M-PF owner: Date of Inspection: 3/11f/i'1 SOIL ABSORPTION SYSTEM(SAS) (locate on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number: leaching chambers,number:_ leaching galleries,number:_ leaching trenches,number, length: leaching fields, number, dimensions: overflow cesspool,number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure,level of ponding, damp soil, condition of vegetation, etc.) CESSPOOLS:_ (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(cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure,.level of ponding,condition of-vegetation, etc.) PRIVY:_ (locate on site plan) Materjals of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation;etc.) revised 9/2/98 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(contirxwed) Property Address: t?tenwrw Owner: Date of Inspection: Vey/DO P SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) ,Of �T ObOYL / o g � a D G v revised 9/2/98 Page 10of11 C SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ��"/ � v�✓ !i/gN Owner: CH-t�p L Date of Inspection: NRCS Report name✓ Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater eet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed.Site(Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators,installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) revised 9/2/98 Page 11of11 6/15/2021 ShowAsbuilt(1700x2800) AT .N� SEWAGE PERMIT NO. �ILLAGL 133 01-(o lam. •��,�-� � - INSTALLER'S NAME a ADDRESS BUILDER OR !OWNER /J71iP !IV DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 0 a v 3 0 o - https://itsqldb.town.barnstable.ma.us:8431/Home/ShowAsbuilt?mp=133026&sq=1 111 1LlACE �: r�� ®�'� A z��� I N S T A LLER'S NAME i ADDRESS 0 U I L D E R OR OWNER DATE PERMIT ISSUED `" DA E COMPLIANCE ISSUED t � A 4 No...0% ?."�R.� �_, .`� - Fps.. w............_. a THE COMMONWEALTH OF MASSACHUSETTS It— BOAR® OF HEALTH qq ( A... .................... Appliratiou for Disputial lVarks Tomitrurtiun ramit Application is hereby made for a Permit to Construct ( 1,1'or Repair ( ) an Individual Sewage Disposal System at: \ ....../!9 ........... ....... . ,"L - .................................-.......... Location Address or Lot No. .............. �rL.....� -•-----___-- - ..._ Owner Address__________________•__•____---_•• Installer Address �� DU Type of Building Size Lot___.:__,�__________________Sq. feet aDwelling—No. of Bedrooms___________________ ____________________Expansion Attic ( ) Garbage Grinder WO p-, Other—Type of Building ____________________________ No. of persons............________________ Showers ( ) — Cafeteria ( ) a' Other fixtures ___________________________________ w Design Flow....................................6_ Ilons per person per day. Total daily flow............................ ........gallons. WSeptic Tank—Liquid capacity_/0QA_gallons Length---6__4 _ Width.#.L2__. Diameter-------`�-__ Depth___Y....... x Disposal Trench—No_____________________ Width.................... Total Length.................. Total leaching area....................sq. ft. Seepage Pit No------------- Diameter____ Z......... Depth below inlet____%_jS..... Total leachingarea__� ...sq. ft. Z Other Distribution box ()<) Dosing tank ( ) Percolation Test Results Performed by........ 1 _ _ !S! 7.__ _____________ Date.!_1P__Q�__.q�.../.��.8 .¢_�� 3>1983 ,aa Test Pit No. 1----- per inch Depth of Test Pit-----�SD..___ Depth to ground water.N'oy____________ f1 Test Pit No. 2....�-;_..minutes per inch Depth of Test Pit____ryV_'�___ Depth to ground water__/VR_____________ ayESr Piz NQ 3 �S. J— -------------------•----.St/----------__---___________________-_-_----____... 5 . Description of Soil....�E'5_T__fe/r_�_Lf_....0_. .`. ..��!��??,,._ "- _ _'_ !P!!�4y__ tI�3 :O1. >-- .` ?S�!"__mE�s,vo E U m�_i "__ 5 '_._.. Q+va.y__ '8+S®�1 . '=:14�'�,,�€,c?..._rr�.. <N _ '�v�v® � " .............. �.--- i�.vis.EQE� UNature of Repairs or Alterations—Answer when applicable................................................................................................ ..------•-----------------------------------------•---------------------------------........__------•-•-••----------------••-----•••----•--•-•------•••-•••---•-•••••-...__._._.._.__._.....---------••- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has een i sued by the boa of health. Si = t Application Approved By- -•• - -•----••-••----------------------------•--...---------•••-••-•--•......._..------ �� 2 Date Application Disapprov for he following reasons______________________________ --••-•-----------------------••------------------...-----------•-•---•---...-----------....-•-------••---•--•-•••-----•...••----•••------•-•..__...•••-•••••-----•---•-••----••--------•••-•--•-•-_----- ^ Date PermitNo......................................................... Issued------------------------••------••----•--------------•- ` Date ,�1 t , Fs.......................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....TOW'A .. ..............OF..... / /7��!!t.�S T .�. .. App' liration for Disposal Works Tonstratr#iun umi# Application is hereby made for a Permit to Construct ( LI-or Repair ( ) an Individual Sewage Disposal System at: -•-------------------------------------------------------•...--•-------------....---...... Location-Address or Lot.No. • '`a? r.�_- aP.. ......S7:>r/'i3t �z�l:. Zl L, 7-1-10 ZA—. C)&.) 63/2/L)A..._.... .... ________ Owner Address --------------------------- ---------- Installer Address U Type of Building Size Lot__�J�.� _Sq. feet r-, Dwelling—No. of Bedrooms.................... ...................Expansion Attic ( ) Garbage Grinder (AJ)C) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures .......................... . W Design Flow...................................."LL gallons per person per day. Total daily flow.........................�-*��--...........gallons. 1x Septic Tank—Liquid capacity.0129gallons Length___�.. .- Width._��.JU... Diameter....... _.. Depth...-_'e �_. Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-------------!_------ Diameter...../ :....... Depth below inlet...... S.r. Total leaching area...P ---sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '-' Percolation Test Results Performed by.._.....L'e4161__.'e..Syo&;r, •�'!':-_-.-•••-- Date._/DaC_:c�'.._/'83 4_74A) 3,/y$3 h-� -- 1.4 Test Pit No. I___. ..='=__.minutes per inch Depth of Test Pit--___�% _..._. Depth to ground water-_/V"............... G14 Test Pit No. 2.....6:.�..minutesper inch Depth of Test Pit----- -- Depth to ground water---/V'............ a Tc S' f�rT wd, 3 y........ j y Description of Soil._._TF_5 P/r...:`// n-t " -pelf,? 8"- �! 3 '= " SfJfVG>>/ ti5c/C330/G .50 /i=t7. �ESY' PST 7 O- t ... /2" St'!' SAAJ 1� .T[JC3.SC/Gr Z...- � Ep..._�a.. .S.,7NQ x iz - ---Pir_ ----- r� GG)!3 ...... SU(9 St-/C-a--2Gr !l"(�. /?JQ,� ='s•S'..._..lc ----T C .c f�lC4 cl�7.F CFTj .- ---- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ----------------------------•-----------•--------------•--------•--•--------•-•---.....---------•--------------------------------------•-------•-------------------------------------•-------••• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITiZ 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has een is ued by the boar of health. Ifollowing ig d '°''`"' - . . ..�,°"" -------------------•-- � -..--........... ate Application Approved By._ 61 ...........------------------------------------------•-••----•-•------. .•..... _..... ------...... DateApplication Disapprove o reasons---------------•------------••--------------------------•------•---------------------------..Da Date.............. .........................................................................................................--••---•------...•-------------•••-•---...-•------------------•--...-----------•--•---••---•--- Date PermitNo............................................................ Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......TO.kWV..............OF.......41�9R_1US.;-4dG.1 '....................... (9rdifiratr of Tomplianrr THIS IS TO CERTIFY, That the Individual Sew*age Disposal System constructed ( Wor Repaired ( ) /f J re,, If i Installer at !`a ' f Q i s ,C�O_sc/.........!7_7 ------------------------------------------- ----------------------------------------------- has been installed in accordance with the provisions of TITLE r of The State Sanitary Codas scribed in the application for Disposal Works Construction Permit No.. .-_.1, ................. dated-,/ ,?,. ....................... THE ISSUA CE THIS CERTIFICATE SHALL NOT BE CONST D AS A GUARANTEE THAT THE SYSTEM WILL UN ION SATISFACTORY. 1L. ` DATE.1L. -r .......... . ...--•...............................•--------•--•..__._Inspector.:.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �� T uffs/ OF........01-212iL�S71--9&e_/�_-. 3 %`9� ............... --.........._.._..........._..----............................... No......................... FEE.Vig............... BisposFal Worb Tnntr ion ' rrntit Permissionis hereby granted........................................................................................ ...................................................... to Construct ( Wor Repair ( ) an Individual Sewage Disposal System at No. ltaT /r ---•-•---- / !/_�.47, uccJILJ -- Street as shown on/theapicat' n for Disposal Works Construction Permit No.................. Dgfed, /) "-��.' •__••-..-••._---- •-•-•••--•--•-••--•-•---••....-•----- -------•----•-----•-•-----•....................- j----••••--------•••----•........................• Bjyrd of Health DATE____..FORM 1255 HOBB & WARREN. INC.. PUBLISHERS ; i I i : � ! I I I ; ! i ! 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