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HomeMy WebLinkAbout0218 MOCKINGBIRD LANE - Health 2A Mockingbird Lane,Marstons Iv ies i t I Commonwealth of Massachusetts Dag— Oo2� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 218 Mocking Bird Property Address Sam Traywick Owner Owner's Name information is required for every Marstons Mills ✓ Ma 02649 5/18/2020 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information !#V- L f on the computer, use only the tab Michael DiBuono key to,move your Name of Inspector cursor-do not DiBuono Sewer And Drain use the return Company Name key. 35 Content Lane „Q Company Address Cotuit Ma 02635 City/Town State Zip Code B� 508-364-9587 S113522 Telephone Number License Number B. Certification I certify thatA am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 5/19/2020 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts a Title 5 Official Inspection Form i, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 218 Mocking Bird L- Property Address Sam Traywick Owner Owner's Name information is required for every Marstons Mills Ma 02649 5/18/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System contains a 1000 Gallon septic tank as well as a concrete distribution box and a concrete leach pit in stone. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments L 218 Mocking Bird Property Address Sam Traywick Owner Owner's Name information is required for every Marstons Mills Ma. 02649 5/18/2020 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3) 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. a. 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: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 218 Mocking Bird V Property Address Sam Traywick Owner Owner's Name information is required for every Marstons Mills Ma 02649 5/18/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: '*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 I Commonwealth of Massachusetts � Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 218 Mocking Bird Property Address Sam Traywick Owner Owner's Name information is required for every Marstons Mills Ma 02649 5/18/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 '/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. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. 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 t5insp.doc•rev.7/2612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 218 Mocking Bird Property Address Sam Traywick Owner Owner's Name information is required for every Marstons Mills Ma 02649 5/18/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 f Commonwealth of Massachusetts �- Title 5 Official Inspection Form �= to Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 218 Mocking Bird V� Property Address . Sam Traywick Owner Owner's Name information is required for every Marstons Mills Ma 02649 5/18/2020 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: Vacant Does residence have a garbage grinder? ❑ Yes ❑ No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 326 GPD Per g ( y g (gp ))' COMM Water Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date t5ins .doc•rev.7/26/201F' P Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �_ le Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 218 Mocking Bird Property Address Sam Traywick Owner Owner's Name information is required for every Marstons Mills Ma 02649 5/18/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.), 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: 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 below): 3. Pumping Records: Source of information: Not provided Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form l� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V / 218 Mocking Bird Property Address Sam Traywick Owner Owner's Name information is Marstons Mills Ma 02649 5/18/2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known) and source of information: System installed 1983 New D Box Installed 2006 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form io Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 218 Mocking Bird Property Address Sam Traywick Owner Owner's Name information is required for every Marstons Mills Ma 02649 5/18/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1.5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1000 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Sludge depth: 3 Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 30" How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping is recommended if not pumped the last two years. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts IrD —, Title 5 Official Inspection Form �a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � / 218 Mocking Bird u Property Address Sam Tra wick Owner Owner's Name information is required for every Marstons Mills Ma 02649 5/18/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. 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.): 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 218 Mocking Bird Property Address Sam Traywick Owner Owner's Name requir at on is Marstons Mills Ma 02649 5/18/2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert New in 2006 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 staining in Distribution box higher than normal level. t5insp.doc•rev.7/26/2018• Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form le Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 218 Mocking Bird Property Address Sam Traywick Owner Owner's Name information is required for every Marstons Mills Ma 02649 5/18/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. 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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 I - Commonwealth of Massachusetts ,P Title 5 Official Inspection Form �= is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 218 Mocking Bird Property Address Sam Traywick Owner Owner's Name information is required for every Marstons Mills Ma 02649 5/18/2020 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Functioning as designed 12. 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 ti Commonwealth of Massachusetts 69 Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4� 218 Mocking Bird Property Address Sam Traywick Owner Owners Name information ati is every Marstons Mills required for eve Ma 02649 5/18/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts � . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 218 Mocking Bird Property Address Sam Traywick Owner Owner's Name information is required for every Marstons Mills Ma 02649 5/18/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 r f Commonwealth of Massachusetts -, Title 5 Official Inspection Form i, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments f; 218 Mocking Bird Property Address Sam Traywick Owner Owner's Name information is required for every Marstons Mills Ma 02649 5/18/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12+ 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: USGS Database Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/201E Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts : & Title 5 Official Inspection Form le Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4� u 218 Mocking Bird Property Address Sam Traywick Owner Owner's Name information is required for every Marstons Mills Ma 02649 5/18/2020 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ❑ A. Inspector Information: Complete all fields in this section. ❑ B. Certification: Signed & Dated and 1, 2, 3, or checked ❑ C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist) completed ❑ D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 5/19/2020 Assessing As-Built Cards TOWN OF BARNSTABLE LOCATION _� c�E.r;L,rr/ // SEWAGE# ')o p h VILLAGE ,f�� s. �/�f ASSESSOR'S MAP&PARCEL 4�—I INSTALLERS NAME& SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO.OF BEDROOMS OWNER /0f/.a ve PERMIT DATE: /g 1 COMPLIANCE DATE: p Separation Distance Between the: " Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY Fri VfQp A GA � f 21` 3" a C o D el 13 https://www.townofbarnstable.us/Departments/Assessing/Property_Values/HMdispiay.asp?mappar=029021&seq=1 1/2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 218 Mockingbird Lane Property Address Melanie L. Lauwers Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/17/14 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms milt'not be altered in any way. Please see completeness checklist at the end of the form. Imng out forms When A. General Information filling outpuler, , on the computer, use only the tab 1. Inspector: key to move your cursor-do not P.Scott Campbell use the return Name of Inspector y key. Cardinal 16 Company Name , 32 Ridgetop Rd. AA Company Address Cotuit Ma 02635 City/Town State Zip Code 508420-1295 S1388 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Need Further Evaluation by the Local Approving Authority 6/17/14 Inspector's Sig re 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments >,M 218 Mockingbird Lane Property Address Melanie L. Lauwers Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/17/14 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 218 Mockingbird Lane Property Address Melanie L. Lauwers Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/17/14 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 218 Mockingbird Lane Property Address Melanie L. Lauwers Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/17/14 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No i Backup of sewage into facility or system component due to overloaded or El ® 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 r than 1/day flow t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form VV, Subsurface Sewage Disposal System Form Not for Voluntary Assessments 218 Mockingbird Lane Property Address Melanie L. Lauwers Owner Owner's Name information is Marstons Mills Ma 02648 6/17/14 required for every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply El ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° . 218 Mockingbird Lane Property Address Melanie L. Lauwers Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/17/14 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 218 Mockingbird Lane Property Address Melanie L. Lauwers Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/17/14 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 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: A& = gy0T_TA,s Sump pump? ® Yes ❑ No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 218 Mockingbird Lane Property Address Melanie L. Lauwers Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/17/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Ins ection Form:Subsurface Sewage Disposal System•Page 8 of 17 P 9 P Y 9 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 218 Mockingbird Lane Property Address Melanie L. Lauwers Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/17/14 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: 1983 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 10" Depth below grade: feet Material of construction: ❑cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 1' 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: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 218 Mockingbird Lane Property Address Melanie L. Lauwers Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/17/14 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 3.5 Scum thickness 4" Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Sludge stick,tape measure Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): System should be pumped at this time. Tank and leach pit. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 i i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 218 Mockingbird Lane Property Address Melanie L. Lauwers Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/17/14 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: 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 t5ins•3/13 Titles Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 218 Mockingbird Lane Property Address Melanie L. Lauwers Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/17/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box is set level and working properly. 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: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 218 Mockingbird Lane Property Address Melanie L. Lauwers Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/17/14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No signs of hydraulic failure, no ponding or damp soil, normal vegetation (grass) Liquid level 18" below invert into leach pit at time of inspection. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 218 Mockingbird Lane Property Address Melanie L. Lauwers Owner Owners Name information is required for every Marstons Mills Ma 02648 6/17/14 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): 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 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) m A � DATA Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 218 Mockingbird Lane Property Address Melanie L. Lauwers Owner Owner's Name information is Marstons Mills Ma 02648 6/17/14 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately A -C ='O4'h" [E_ck oa 31'3" �o C el �+3611 l:1 D T` fl r t5ins-W 3 Title 5 Official Inspection Form:Subsurface Swage Disposal System•Page 15 of 17 1 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 218 Mockingbird Lane Property Address Melanie L. Lauwers Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/17/14 page. CityTrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow well's Estimated depth to high groundwater: 12+ 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: Excavation at time of inspection. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Tdle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 218 Mockingbird Lane Property Address Melanie L. Lauwers Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/17/14 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE V OCA'PION �?/ �..�. SEWAGE#. 'c ILLAGE !='t ,s ASSESSOR'S MAP&PARCEL INSTALLERS NAME&P-ZONE NO.„43rj no SEPTIC TANK CAPACITY LEACHING FACILITY:(type) NO. OF BEDROOMS .� (size) OWNER /A"/r�.d/ri' j.4�i✓C;/?S Dkzc` PERMIT DATE: ,S COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply Well and Leaching Facility(If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) FURNISHED BY Feet N t� N, z `o � fl � 13 �Lt � 'ai r F 66 TITLE 5 �h�. 4 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS ��,«' SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM - _ - PART A CERTIFICATION Property Address- 218 Mockingbird Lane Marston Mills Address: '7 Owner's Name:_ Melanie Lauwers `? Owner's-Address: Same ✓`�/ cj t � Date of Inspection 4-27-06 Name of Inspector.(please print) Michael A.Burnie Company Name: D.J.Burnie&Sons Septic Services Mailing Address: 307A Commerce Park North,South Chatham,MA 02659 Telephone Number: 508-432-7420 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 CUR 15.000).The system: Passes x Conditionally Passes =Needs Fr Evaluation byJLocal Aproving Authority Fails Inspector's Signature: Date: 5-8-06 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the condition 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. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 21tk Mockingbird Lane Owner Melanie Lauwers Date of Inspection4-27-06 Inspection Summary:Check A,B,C,D or E IALWAYS complete all of Section D A.System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exists.Any failure criteria not evaluated are indicated below. Comments: sample B.System Conditionally Passes: x 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. _no_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: yes Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipes)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 _x_Distribution box is leveled or replaced ND explain: the system required pumping more than times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): —broken pipe(s)are replaced Obstruction is removed ND explain: OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 218 Mockingbird Lane Owner Melanie Lauwers Date of Inspection: 4-27-06 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 aseptic tank and SAS and the SAS is within a Zone I oft 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: OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 218 Mockingbird Lane Owner: Melanie Lai wers Date of Inspection: 4-27-06 D.System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No x Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool x Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool x Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool x Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow x_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped x Any portion of the SAS,cesspool or privy is below high ground water elevation. x Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. x Any portion of a cesspool or privy is within a Zone 1 of a public well. x Any portion of a cesspool or privy is within 50 feet of a private water supply well. x Any portion of a cesspool or privy is less than 100 fat but greater than 50 fat from a private water supply well with no acceptable water quality analysis.(This system passes if the well water analysis, performed at a DEP certifted laboratory,for cdiform bacteria and volatile organic compounds indicates that the well is free from pollution from that faeility 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.] no (Yes/No)the system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15303,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 most serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No — — The system is within 400 feet of a surface drinking water supply — — The system is within 200 fat 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 B 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. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 218 Mockingbird Lane Owner. Melanie Lauwers Date of Inspection: 4-27-06 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No x _ Pumping information was provided by the owner,occupant,or Board of Health x Were any of the system components pumped out in the previous two weeks? x _ Has the system received normal flows in the previous two week period? x Has large volume of water been introduced to the system recently or as part of this inspection? n/a _ Were as built plans of the system obtained and examined?(If not available note as N/A) a _ Was the facility or dwelling inspected for signs of sewage back up? x _ Was the site inspected for signs of break out? _x_ _ Were all system components,including the SAS,looted on site? x _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the bates or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? x _Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption:System(SAS)on the site has been determined based on: Yes No x _ Existing information.For example,a plan at the Board of Health. x_Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PARTC SYSTEM INFORMATION Property Address: 218 Mocldn bird Lane pe g Owner. Melanie Lauwers Date of Inspection: 4-27-06 FLOW CONDTTIONS RESIDENTIAL Number of bedrooms(design):unknown Number of bedrooms(actual): 3 per owner___prior report has house listed as a 4 bedroom DESIGN flow based on 310 CUR 15203(for example:110 gpd x#of bedrooms):Unknown,no plan on file Number of current residents:_unkonwn_ Does residence have a garbage grinder(yes or no): n Is laundry on a separate sewage system(yes or no): n [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use(yes or no): n Water meter readings,if available(last 2 years usage(gpd)):04-70,000=192gpd 05- 65,000=178gpd Sump pump(yes or no): n Last date of occupancy: current COMMERCIAIANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): 9d Basis of design flow(seats/persons/sgft,etc.) Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:_1000 gallons on 9-30-05 D.J.Burnie&Sons Was system pumped as part of the inspection(yes or no): n If yes,volume pumped: gallons-How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM x Septic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained ITom 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 15 years+- Were sewage odors detected when arriving at the site(yes or no): n rJ OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PARTC SYSTEM INFORMATION(continued) Property Address: 218 Mockingbird Lane Owner: Melanie Lauwers Date of Inspection: 4-27-06 BUILDING SEWER(locate on site plan) Depth below grade: 16" Materials of construction: cast iron x 40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting evidence of leakage,etc.): The main line was in proper working condition. SEPTIC TANK* x (locate on site plan) Depth below grade:_10" Material of construction: x concrete_metal_fiberglass polyethylene_other(explain) If tank is metal list age:_is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 1000gallons Sludge depth: r Distance from lop of sludge to bottom of outlet tee or baffle: Scum thickness: I- Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid.levels as related to outlet invert evidence of leakage,etc.): GREASE TRAP:_(locate on site plan) Depth below grade: Material of construction:_concrete_metal fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert.evidence of leakage,etc.): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address 218 Mockingbird Lane Owner: Melanie Lauwers Date of Inspection: 4-27-06 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction:—concrete_metal_fiberglass_polyethylene_other(explain): Dimensions: '— Capacity: gallons Design Flow: gallons/day Alarm present(yes or no):_ Alarm level:_Alarm in working order(yes or no):_ Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: x _(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert 0" _ Comments(note if box is level and distribution to outlets equal,any evidence of solids canyover,any evidence of leakage into or out of box,etc.): The d box is rotted and needs to be replaced PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 218 Mockingbird Lane Owner: Melanie Lauwers Date of Inspection: 4-27-06 SOIL ABSORPTION SYSTEM(SAS): x (locate on site plan,excavation not required) If SAS not looted explain why: Type _x Leaching pits,number•. 1_ _Leaching chambers,number._ _Leaching galleries,number._ Leaching trenches,number,length:_ _Leaching fields,number,dimensions:_ Overflow cesspool,number:_ _Innovativetalternative system Typetname of technology:_ Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): The leach pit has 4'6"of standing water in it CESSPOOLS:_(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer. Depth of scum layer. Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no) Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:_(locate on site plan) Materials of construction: Dimensions: Depth of solids. Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 21&Mockingbird Lane Owner: Melanie Lauwers Date of Inspection: 4-27-06 SITE EXAM Slope yes Surface water Check cellar Shallow wells Estimated depth to ground water 30'+-der prior report feet Please indicate(check)all methods used to determine the high ground water elevation: x Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: _Checked with local excavators,installers-(attach documentation) x Accessed USGS database-explain: SDW253 Zone B Level 48.5-2.7'=32.4r adjustment You must describe how you established the high ground water elevation: Referenced prior report done on 4-18-97 showing groundwater at 30'+- 'OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:. 219 Mockingbird Lane Owner: Melanie Lauwers Date of Inspection: 427-06 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. SEE ATTACHED axFOI[tM..lqor]FORvOLUNTARYASSESSMEMSubSUMACESEWAGEDAWOSAL - SYSTMMWECUONFORM PAIRr c pmperWAddFCM-at SSWr4M CWSMA9MDlSPO6ALSYMW � s�oat�stt ►p refaen<xbmdmwks p��asitci mffts� ke p�rmem ,ram,Locate aH� 1081het lior� P TOWN O/FBARNSTABLE �y ' LOG Q ITON o2l� / iC1 r ng,�io e/ E/t/ SEWAGE# QQ Q (0 r71 9 «VILLAGE Ar ii5 ASSESSOR'S MAP&PARCEL da %' INSTALLERS NAME&PHONE NO.�.Pdf4°�/�Gc*ram.�- ���S (SW-) y3a -741.2 o SEPTIC TANK CAPACITY LEACHING FACILITY: (type) . (size) NO.OF BEDROOMS "z OWNER"! 111614,ve 14✓E✓cRp 5 PERMIT DATE: Ile � � COMPLIANCE DATE: � 0 " e Separation Distance Between the:: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY P► � I:�A � r tP �u 13 3 _ GI 5. TOWN OF BARNSTABLE 1,04,,ATION 41 --- .0 SEWAGE VILLAGE DNS K L& ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER Vn G Aga_ PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by �/ 4 t No. 3 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes apphrAtton for Dtgonl *p5tem couttrulction permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.,;218 676 � f� Ow e Address and el.No. fns Assessor's Map/parcel v �� �S/v /01 Y) Installer's Name,Address,and Tel. V713of �> Designer's N e,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Na ure of Re airs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issu th B and a Signed Date Application Approved b _ _ Date Application Disapproved by: Date for the following reasons { Permit No. �_` Date Issued 4 � f No. r Fee ' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZIPPYicatior� for Digogal *p�terr' ,Con.5truction Permit Application for a Permit to Construct O Repair O Upgrade O Abandon O ❑ Complete System ❑Individual Components Location Address or Lot No.a18 /OC�f"�✓iy' f/��y,n Ow s_Na e Address and 7el.No. Assessor's Map/Parcel 0 OoZl Installer's Name,Address,and Tel.No5"q9C Designer's Na e,Address and Tel.No. so Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) _ Other ` Type of33�'ilding-. k € - r. .. t No:of Persons' . Shower`s( )- Cafeteria( ) ' - Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date ` Title Size of Septic Tank Type of S.A.S. Description of Soil j +I Nature of Repairs or Alterations Answer when applicable) ( PP ) i -l�oki P -1. 4 Date last inspected: Agreement: 1_�,- The`undersigned agrees_to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of,Title 5 of the E6vironmental Code and not to place the system in operation until a Certificate of Compliance has been issued�hy th' 'ard aIt, r Signed ., Date 'Application Approved b Date . Application Disapproved by. .f )Date for the following reasons = y Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( Upgraded ( ) Abandoned( )by at t l as been constructed in accordance with the provisions of Title 5 and thkol Disposal System Construction Permit No. aS!��(b -3 dated /� 1 Installer Designer #bedrooms Approved design flow gpd The issuance of this permit shall not be/construed as a guarantee that the system wil'1'functodes gned. Date ��if�P Inspector -- _--- -'-— --—— —————— a —n---- ,----9 --V --- :� No. ^ 3 ! Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS Bigonl �&pgtem Construction Permit Permission is hereby gra ted EtConstruct ( Repa r ( Upgrade ( ) Abandon ( ) System located at e �L rgA and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Construction us t b completed within three years of the date of this e t Date Approve6-by COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFF DEPARTMENT OF ENVIRONMENTAL PROTE ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 A '!t d7 a , 30 TRUDY CORE WU11"F.WELD �8 �9 Secretary �.. Governor �ly�p Tg6�AVID B.STRUHS ARGEO PAUL CELLUCCI C loner Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION -- f Property Address: LlG!/1 41'No� Z. 2 Address of Owner:�,,h iC Date of Inspection: O( -d�If different)Name of Inspector: . Company Name, Address and Telephone Number: 'R�'\Atiit'lL. �-tuv��c�M��.�ham. �•O�ow a��y 1 nnbr��t Mn. o2.(�y�t C.SOi�t 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: APasses _ Conditionally Passes _ Needs Further Evalu on By the Local Approving Authority Fails Inspector's Signatur r1 L Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority 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 of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: A_ I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. 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, 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 conforming septic tank as approved by the Board of Health. (revised 11/03/95) i� Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property�res /���©c�l•�','w��dVC� �c�c.� . /(�-��u-- / �--ILLS Owner: aC Date of Inspection-, ji 1 B] SYSTEM rCC1NDITIONALLY PASSES (continued) Sewagelbackup or breakout or high static water level observed in the distribution bo is due to broken or-obstructed p (s) or due to a broken, settled or uneven distribution box. The system will pas 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 pumping more than four times a year due to broke 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 C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of alth in order to determine if the system is failing to protect thf public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMI S THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAF AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface ater Cesspool or privy is within 50 feet of a border' g vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEAL H (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THK THE SYSTEM IS FUNCTIONING IN A MANNER T AT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system'has a septic tank and it absorption system and is within a Zone I of a public water supply well. The system has a septic tank an soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank a d soil absorption system and is less than 100 feet but 50 feet or more from a private wate supply well, unless a well w er analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from th facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than ppm- 3) OTHER (revised 11/03/95) 2 —_ 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) ' Property Address:'C-9 le. Lc&r,.o • �� /�1.�U(� Owner: G�t 2s'L. Date of Inspection: D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as def ed in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to det mine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface ters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to n overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or availabl volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT a to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or rivy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 fe of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Z e I of a public well. Any portion of a cesspool or privy is within feet of a private water supply well. _ Any portion of a cesspool or privy is less an 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If th well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic co ounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large sy tems in addition to the criteria above: The system serves a facility with a esign flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the vironment because one or more of the following conditions exist: the system is within 00 feet of a surface drinking water supply the system is wit n 200 feet of a tributary to a surface drinking water supply the system is I cated in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a public water upply well) The owner or operator of an such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR .0 and 6.00. Please consult the local regional office of the Department for further information. (revised 11/03/95) 3 { ( SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:-w /Coi,�hi r� LacfL , dS Owner: G . cC,cz G sV C�2 Date of Inspection: Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rate 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, excluding the Soil Absorption System, 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 or approximated by non-intrusive methods. NThe facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 I • 'n SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION,/ Property Address:ve 9V, as Owner: � 2— Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow:*-'W allons Number of bedrooms:2-1zk Number of current residents:64 Garbage grinder(yes or no): Laundry connected to system (yes or no): Seasonal use (yes or no): Water meter readings, if available: Ajim y — Last date of occupancy: COMMERCIAL/I N D USTRIA L• Type of establishment: Design flow:_gallons/day. 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: Q OL[t1,etxn Arj System pumped as part of inspection: (yes or no) If yes, volume pumped: allons Reason for pumping: 14�/N /41dC�— 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) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: P Sewage odors detected when arriving at the site: (yes or no) / (revised 11/03/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:- —/`�© ��tiU Za � � Owner: Date of Inspection: SEPTIC TANK: (locate on site p n) Depth below grade: f Material of construction: 41concrete _metal _FRP—other(explain) Dimensions: Ctri 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: Comments: (recommendation for pumping, con 'tion of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,structural integrity, evidence of I akage, etc.) t N rt C GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP—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: 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 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: C � c-C���ie2, Date of Inspection: oZ/ TIGHT OR HOLDING TANK: NO (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP—other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:VS (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) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 11/03/95) 7 r , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address,C /ZOGI� 1j zol_ Owner: G G(J��R/2✓Z__ Date of Inspection: a.,41,741_ SOIL ABSORPTION SYSTEM (SAS):.q (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Pmrvnts: (note ddiition of foil, signs of hydraulic failure, level of ponding, c oiti f Ypeetation,etcj 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: i(locate on site plan) P Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 11/03/95) 8 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: G Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' DEPTH TO GROUNDWATER Depth to groundwater:-a �feet method of determination or approximation: Q-$ taro D "S- (revised 11/03/95) 9 5