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HomeMy WebLinkAbout35/37 SANDY NECK ROAD - Health 35/37 Sandy Neck Road West Barnstable R Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface.Sewage Disposal System Form -Not for Voluntary Assessments ,M Great Island Sandy Neck Map& Parcel 183-001 c� Property Address Kia Cole Owner Owner's Name information is required for W Barnstable Ma. 02668 9/14/2007 every 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. Important: A. General Information When filling out ��. �� forms on the 1 ; computer,use 1. Inspector: �l only the tab key .�+ti_� 1 � t v­o`• , to move your Robert Paolini cursor-do not Name of Inspector use the return z key. Capewide Enterprises,LLC Company Name r� P.O.Box 73 Company Address j.. CID Centerville . Ma. 02632 r" rn City/Town State Zip ode (508)428-4028 S14454 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.-) am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Ne7,Zlua ' n by the Local Approving Authority 9/14/2007 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. Sandy Neck•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M Great Island Sandy Neck Map & Parcel 183-001 Property Address Kia Cole Owner Owner's Name information is required for W Barnstable Ma. 02668 9/14/2007 - every 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: ® 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: The septic system is in proper working order at the present time.System was dry at time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent: System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed Sandy Neck•08'06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M Great Island Sandy Neck Map& Parcel 183-001 Property Address Kia Cole Owner Owner's Name information is W Barnstable Ma. 02668 9/14/2007 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally'Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than.4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the,Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. Sandy Neck•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M Great Island Sandy Neck Map& Parcel 183-001 Property Address Kia Cole Owner Owner's Name information is required for W.Barnstable Ma. 02668 9/14/2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in 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 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. Sandy Neck•08'06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M Great Island Sandy Neck Map & Parcel,183-001 Property Address Kia Cole Owner Owner's Name information is required for W Barnstable Ma. 02668 9/14/2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ E 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. Sandy Neck•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official -Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Great Island Sandy Neck Map & Parcel 183-001 Property Address Kia Cole Owner Owner's Name information its W required for Barnstable Ma. 02668 9/14/2007 every.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? ® El information 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)] Sandy Neck•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ^M Great Island Sandy Neck Map& Parcel 183-001 Property Address Kia Cole Owner Owner's Name information is required for W Barnstable Ma. 02668 9/14/2007 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 1 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage d Well Water 9 ( Y 9 (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: unknownDate Commercial/Industrial Flow Conditions: Type of Establishment: i n on 310 CMR 15.203 Des flow based g ( ) 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: Last date of occupancy/use: Date Other(describe): Sandy Neck-08/06 Tifle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 f �. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Great Island Sandy Neck Map& Parcel 183-001 Property Address Kia Cole Owner Owner's Name information is required for W Barnstable Ma. 02668 9/14/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: . Source of information: 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) ❑ 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 ® No Sandy Neck-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 f - Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M Great Island Sandy Neck Map& Parcel 183-001 Property Address Kia Cole Owner Owner's Name information is required for W Barnstable Ma. 02668 9/14/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 1 Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ® other(explain): orangeberg Distance from private water supply well or suction line: 100, feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. 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: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No ---------------------------------------------------------------------------------------------------------------------------- Dimensions: Sludge depth: 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 Distance from bottom of scum to bottom of outlet tee or baffle I How were dimensions determined? Sandy Neck•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM Great Island Sandy Neck Map& Parcel 183-001 Property Address Kia Cole Owner Owner's Name information is required for W Barnstable Ma. 02668 9/14/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 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): Sandy Neck•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M Great Island Sandy Neck Map& Parcel 183-001 Property Address Kia Cole Owner Owner's Name information is required for W Barnstable Ma. 02668 9/14/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) 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 Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet-invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Sandy Neck•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M Great Island Sandy Neck Map & Parcel 183-001 Property Address Kia Cole Owner Owner's Name information is required for W Barnstable Ma. 02668 9/14/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (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: 1 ❑ 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.): Sandy dry soil.No signs of hydraulic failure.Overflow cesspool was dry at time of inspection. Sandy Neck•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M Great Island Sandy Neck Map& Parcel 183-001 Property Address Kia Cole Owner Owner's Name information is required for W Barnstable Ma. 02668 9/14/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 2 1main 1overflow Depth—top of liquid to inlet invert na Depth of solids layer na Depth of scum layer none Dimensions of cesspool 6'x6' Materials of construction Concrete block Indication of groundwater inflow ❑ Yes ® No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i Sandy dry soil.No signs of hydraulic failure.Main cesspool was dry at time of inspection. 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.): Sandy Neck•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 r G Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .'" Great Island Sandy Neck Map& Parcel 183-001 Property Address Kia Cole Owner Owner's Name information is W Barnstable Ma. 02668 9/14/2007 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. I 1 I l \ a C& . A y 1. f , Yy 14) well 10 20 Feet Sandy Neck•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Great Island Sandy Neck Map& Parcel 183-001 Property Address Kia Cole Owner Owner's Name information is required for W Barnstable Ma. 02668 9/14/2007 every 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 ground water: Bottom of CP 5' 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: Used:Gaherty& Miller Model 12/16/94 ground water elevations. Used:USGS Observation Well Data June 1992. Used: Technical Bulletin 92-000-01 plate#2 annual ranges of ground water elevations. Sandy Neck•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 DATE: 12/5/01 ---- PROPERTY ADDRESS�Great Island Sandy_Neck_ West-Barnstale_--------- ` 0 Mass. 02668 ------------------------ On the above date, I inspected the septic system at the above address. This system consists of the following: 1 . "2-6 'XV block cesspools in series. Based on my inspection, I certify the following conditions: 2. This is not a title five septic system. ,.3. This is a sewage system that is in proper working order at the present time. 4 . Main cesspool has 16" of water in it and the overflow cesspool is,:dry. 5. Both cesspools are structurally sound and show no vidence of water intrusion.. - /J SIGNATURE:1' Name:_,L. P N_acomber ,Jr�------ _ - �} Company: JoseTh_P. Macomber_& Son , Inc . Address:— Box,-66------------- Ur-� G0 tool --Centerville , Ma__02632-0066 TOWN TH0 T BLE Phone: 508-775-3338 --------------------- THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY rJOSEPH P.�MACOMBER & SON, INC. Tan ks-Cesspools-Leachflelds Pumped & Installed Town Sewer Connectlons P.O. Box 66 Centerville, MA 02632-0066 775-3338 775-6412 TOWN O BARNSTABLE��15f , 1 .2-1 0 LOCATION �/ SEWAGE # VILLAGE .4i0, ASSESSOR'S MAP & LOT— INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type/4/Xp � �d > (size) NO. OF BEDROOMS_._ BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist OL within 300'feet le hi cility) Feet t S Furnished by ----- s'i,apt_.. -- +3—0-P5----- per-- _ _. 04 ON OWN.- �--\ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL. PROTECTION TITLE 5 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:Great Island Sandy Neck West Barnstable,Mass. Owner's Name: Susan Martin Owner's Address: 12/S/0 1 Date of Inspection: 111 South Hill Road New Boston,New Hampshire, 03070 Name of Inspector: (please print) J.P. Macomber Jr. Company Name:Joseph P. Macomber & Son Inc Mailing Address: P=O= Box 66 rani rvllle Ma 02632 Telephone Number: 508-775-3338 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: A' Passes % _ Conditionally Passes _ Needs Further Evaluation by the Local Approving Authoriry F ils Inspector's Signature dL�� 1 Date: e The system inspector sha ubmit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. if the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ""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 I I Page 2 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Great Island Sndy Neck es . Owner: Susan Martin Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D System Passes: b 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 sewage system is in proper working order at the present time. Main pool has 1' of water in it and Me overflow cesspool is dry. 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. �(,A&( The eptits ;subDstartial s-netal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exh> 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: ,tW P— Observation of sewage backup or break out or high static water level in th distribution box ue to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: QVl The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 I Page 3 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:Great Island Sandy Neck West Barnstable,Mass. Owner: Susan Ma t ' n Date of Inspection: C. Further Evaluation is Required by the Board of Health: Alb Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail t:nless 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. tf� 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 The sewage system consists of 2-6 'X8 ' Block cesspools inseries The main cesspool has 16" of water and the overflow is dry. 3 Page 4 of 1 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Add ress:Great Island Sandy Neck est Barnstal)ie,mass . Owner:Susan Martin Date of Inspection: 1 2 5 01 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes Y�Aackup 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 h day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number f times pumped 0. _ Any portion of the SAS, cesspool or privy is below high ground water elevation. 22 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ y 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 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. Lange Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 g.pd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 'Page 5 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:Great Island Sandy Neck West arns a e,Mass. Owner: Susan Martin Date of Inspection: 12 5 01 Check if the following have been done. You must indicate`yes"or"no"as to each of the following: Yes No Zpumping information was provided by the owner, occupant, or Board of Health A 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&0 _ 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 ariholes uncovered,opened, and the interior of the tank inspected for the condition of the b ffles 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 no / _/_/ Existing information. For example, a plan at the Board of Health. k1 _ 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)) 5 -Page 6 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:Great Island Sandy Neck arns a e, ass. Owner: Susan Martin Date of Inspection: 12 5 01 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):—j— Number of bedrooms(actual): � DESIGN flow based on 310 CM j4R, 15.203 (for example: 110 gpd x# of bedrooms):" /h Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system (yes or no);�_,D [if yes separate inspection required] Laundry system inspected If or no): Z Seasonal use: (yes or no): If the well has Water meter readings, if available(last 2 years usage(gpd)): f��, ,�,a/pr Sump pump(yes or no):d,0 Last date of occupancy: E� not been tested iU f�,17 in the last 12 months it should be COMMERCIAL/INDUSTRIAL done at this time. Type of establishment: See pages 6A & 6B Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc.): A!/` 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):&�f Water meter readings, if available: f� Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): If yes, volume pumped: 69 gallops-- How was'quantity pumped determined? Reason for pumping: TEE OF SYSTEM /(JU Septic tank,distribution box, soil absorption system 4Single cesspool 0verflow cesspool �vY 6Shared 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 syst�ym owner) /LOTight tank �Attach a copy of the DEP approval 4U6)Other(describe): A p oximate ao of al ompon is at�stalled (if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): 6 III 7 of Page o , OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Great Islad Sandy Neck Barnstable,Mass. Owner:Susan Martin Date of Inspection: 12/5/01 BUILDING SEWER (locate on site plan) • �I Depth below grade: 3;z Maier als of construction: cast iron 4040 PVC j2other�explain): '1r 4A)*e4&M Distance from private water supply well or suction line: /l� f' Comments(on condition ofjoints, venting, evidence of leakage, etc.): Joints appear tiaht.No evidence of leakage.System is vented through the house vents. SEPTIC TANIC/f�e+01ocate on site plan) Depth below glade: 104 Material of construction:�/`concrete, metal�fjfiberglass/L' olyethylene 06ther(explain) ,6/ If tank is metal list ageoo Is age confirmed by a Certificate of Compliance (yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: ,>! Distance from to of sludgg to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bosom of scum to bottom of outlet tee o baffle: How were dimensions determined: ZI Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of.leakage, etc.): Septic tank is not present. GREASE TRAW44t locate on site plan) Depth below grade: 10 Material of construction:/?, concretellAmetall&berglass,�olyethylenet�other (explain): 14 Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bosom of scurp to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease trap is not present. Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Great Island Sandy Neck Barnstable,Mass. Owner: Susan Martin. Date of Inspection:12/5/01 TIGHT or HOLDING TANK4ve- (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: AM Material of construction: 41 concrete,42/�metal4P, fiberglass,&f polyethylene,6/4 other(explain): �� Dimensions: Capacity: gallons Design Flow: eallons/day Alarm present(yes or no): Alarm level: .//l Alarm in working order(yes or no): Date of last pumping: A114 Comments(condition of alarm and float switches, etc.): Tight or holding tanks are not present. DISTRIBUTION BOY (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 44 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box, etc.): Distribution box is not present. PUMP CHAMBEP.<&/,(locate on site plan) Pumps in working order(yes or no): 1 Alarms in working order(yes or no):� Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Pump chamber is not present. 8 Page 9 of I I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Great Island Sandy Neck ar3 nstable,Mass. Owner: Susan Martin Date of Inspection:12/5/01 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) 2-6 'X8 ' block cesspcwls in If SAS not located explain why: Located- Y �ge leaching pits,number: C leaching chambers,number:O d leaching galleries,number: leaching trenches,number, length: 0 leaching fields,number, dimepsions: overflow cesspool, number: I technology: innovative/altemative system Type/name of gy: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): Loamy sand to f ' nA C . No signs of hydraulic- fa; 1 i,ra or ponding.Soilso as 16" of water and the overflow is dry. No signs of water intrusion. CESSPOOLS: (cesspool must be pumped as part of inspect ion)(locate on site plan) Number and configuration: � '�/ Depth—top of liquid to inI invert: Depth of solids layer: 11 Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): D Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): Same as above - PRIVY,Ikt(locate on site plan) Materials of construction: �7 Dimensions: Depth of solids: _ Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): Privy is not presen- 9 Page 10 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:Great Island Sandy Neck Barnstable,Mass. Owner: Susan Martin Date of inspection: 1 2/5/01 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of.the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 0 10 a, 'Pagel] of l l OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:Great Island Sandy Neck Barnstable Barnstable Owner: Susan Martin Date of Inspection: 1 2/5/01 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water IS feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system.design plans on record-if checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Used; Gahrety & Miller Model_ Gr9iind water ahnue spa level IJSC;S_ nhsprvatinn wel-1 nat'a June 19A2 JJSG 92-000-1 Plate 2 Tup of Ground r r ' Leaching Pit �: ,eet t Groundwater:19'Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method Therefore, the vertical separation distance between the bottom of the leaching pit and the adjusted groundwater table is X411 feet. 11 I ]•tT..{T rRiTT.T—«�JRf•I.RTRTT7'ti'TfT.ITR:•.1r.•rRfl711RTRT1 T1R111[J*'.v�TsrtRT �����...T r.. TOWN OF Barnstable WARD OF HEALTH SUIISURF,ICF 9FWA(IF DISPOSAL SYSTF,M INSUCTION FORM - PART D .- CERTIFICATION •••Tt1�T••.••. .—T.t IT.�.�TTI.R 7•ftl'R Tr'TT1r.RT.T TIT.Tt'r—!,•1."IIITR7 RRM�'rRrtTCvir�'A"RtT'1 TR R -TYPE OR PAINT CI.EARL)'- PROPERTY INSPECTOD STREET ADDRES$ Great Island Sandy Neck Barnstable ASSESSORS MAP , DLOCK AND PARCEL OWNER' s NAME Susan Mart-in PART D - CERTIFICATION NAME OF INSPECTOR Joseph P. Macomber Jr. COMPANY NAME Joseph P. Macomber & S.4n Inc COMPANY ADDRESS P..O. Box 66 Centerville Ma 02632 Streat Town or City Stat9 EIP COMPANY TELEPHONE (508 ) 775 - 3338 FAX (508 ) 790 - 1578 m CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposaj system at 0ecommenda his address and that the information reported is true , accurate , and omplete as of the time of ,inspection . The inspection was performed and any tions regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems , Che7cone : y System PASSED The inspection «hich I have conducted has not found any information which indicates that the system fails to adequately protect public health or, Lhe environment as defined in 310 CMR 16 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* \ The inspection which I have con ilcted has found that the system fails to protect the public healthy and the environment in accordance with Title ,5 , 310 CMR 16 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this in pection orm . " I Inspector Signature � ;l7fG Date 1 ne copy of this tification must be provided to the OWNER, the BUYER ( where applioable ) and the 130ARD OF llL+'AL'I'll, + If the inspection FAILED , the owner or.."operator shall u within one year of the date of the inspection, unless allowed dortrequiredm otherwise as provided in 3.10 CMR 16 . 305 , partd .doc