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HomeMy WebLinkAbout0051 ALTHEA DRIVE - Health 51 Althea Drive; -i � � 333a1 � � � 333- 6?S Commonwealth of Massachusetts its w Title 5 Official Inspection Form ! I Subsurface Sewage Disposal System Form.-Not for Voluntary AssessmentsXelf 51 Althea Dr ;fir Property Address a. Dave Rioux ' Owner Owner's Name information is C required for every Cummaguid MA 02637 5-9-19 ;•_ 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. A. Inspector Information ��# i 3g �►.- , Shawn Mcelroy Name of Inspector Upper Cape Septic Seivices Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S 13971 Telephone Number License Number B. Certification V I certify that:) am a DEP approved system inspector in full,compliance with Section 15.340 of Title 5 (310 CMR 15.000);I have personally inspected the sewage disposal system at theproperty 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 , 5-9-19 I spector'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 ' r� ,w Title 5 Official Inspection Form ! i�i Subsurface Sewage Disposal System'!Form -Not for Voluntary Assessments r U 51 Althea Dr Property Address Dave Rioux Owner Owner's Name information is required for every Cummaguid MA 02637 5-9-19 page. City/Town 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:. .'a ' ® 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 is in good working order with no sign of failure. 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," explain. lain. P P 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): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 t I r Commonwealth of Massachusetts Title 5 Official Inspection Form ! iI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments { W >` 51 Althea Dr Property Address Dave Rioux Owner Owner's Name information is Cumma uid MA 02637 5-9-19 required for every -- q page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 74 ; 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 El ND (Explain below): I ❑ obstruction is removed ❑ Y ON ❑ 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 ON ❑ ND (Explain below): ❑ obstruction is removed ❑Y ON ❑ 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 ' Commonwealth of Massachusetts Title 5 Official Inspection Form i MI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Althea Dr Property Address Dave Rioux Owner Owner's Name information is required for every Cummaquid MA 02637 5-9-19 page. Cityrrown 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 t Commonwealth of Massachusetts f Title 5 Official Inspection Fora i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Althea Dr Property Address Dave Rioux Owner Owner's Name information is required for every Cummaquid MA 02637 5-9-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) t. L . 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No , El ® Static liquid level in the distribution boz 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 Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOTdue 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 1-00 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. ❑ ® r 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts r� ;w,. Title 5 Official Inspection Form -I Subsurface Sewage Disposal System Form -Not for.Volunta Assessments 9 p Y rY r a y ,a`. 51 Althea Dr Property Address Dave Rioux Owner Owner's Name information is required for every Cummaq uid MA 02637 5-9-19 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? ® Ej 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? ® ❑ Wasthe 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 Inspecton Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection. Form �i Subsurface Sewage Disposal System Form -Not for�Voluntary Assessments 51 Althea Dr Property Address Dave Rioux r Owner Owner's Name information is required for every Cummaquid MA 02637 5-9-19 page. CitylTown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: - Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: 1 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 Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 2019 Date t5insp.doc-rev.7/2 612 0 1 8. Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 it I Y Commonwealth of Massachusetts 4. Title 5 Official Inspection Form i� wa Subsurface Sewage Disposal System Form -Not for,Voluntary Assessments (N <,l :- ->' 51 Althea Dr Property Address Dave Rioux Owner Owner's Name information is required for every Cummaq uid MA 02637 5-9-19 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: N/A 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 r Commonwealth of Massachusetts ' # Title 5 Official Inspection Fora w:� l �i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Althea Dr Property Address Dave Rioux - Owner Owner's Name information is required for every Cummaguid MA 02637 5-9-.19 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: 1990 Were sewage odors detected when arriving at the site? ;❑ Yes ® No 5. Building Sewer(locate on site plan): _ Depth below grade: 18"feet - Material of construction: ❑ cast iron ' Z 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. I t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 1 Commonwealth of Massachusetts r� Title 5 Official Inspection Form Y-i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Althea Dr Property Address Dave Rioux Owner Owner's Name information is required for every Cummaquid MA 02637 5-9-19 page. City/Town State Zip Code Date of Inspection D. System Information (cor:t.) - 6. Septic Tank(locate on site plan): 12" 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: 1000 gal Sludge depth: 12" Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts ;w Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments:I•% .� 51 Althea Dr n• �� Property Address Dave Rioux Owner Owner's Name information is required for every Cummaquid MA 02637 5-9-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): 4 Depth below grade: feet i. 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 i nspecti on)(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 • I Commonwealth of Massachusetts . Title 5 Official Inspection Form ! i)"I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r a rr' 51 Althea Dr Property Address Dave Rioux Owner Owner's Name information is Cumma uid MA 02637 5-9-19 required for every q 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 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.): Good condition with water at working level and no sign of back-up from pit. t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 I Commonwealth of Massachusetts ,w Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . 51 Althea Dr , Property Address Dave Rioux Owner Owner's Name information is Cumma uid MA 02637 5-9-19. required for every q page. City/Town 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: , 1-600 gal ❑ 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 c ',, Commonwealth of Massachusetts �W N. Title 5 Official Inspection Form 113i Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments a 51 Althea Dr Property Address Dave Rioux Owner Owner's Name information is required for every Cummaquid r MA 02637 5-9-19 page. City/Town 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.): Leach pit in good condition and empty at inspection with no sign of back-up into d-box or surrounding stone. Inlet enters into riser. 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 t Commonwealth of Massachusetts Title 5 Official Inspection form w tl Int Subsurface Sewage Disposal System Form.-Not for.Voluntary Assessments U 51 Althea Dr Property Address Dave Rioux Owner Owner's Name information is umma uid MA 02637 5-9-,19 required for every C Q ' page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): i i r ..5 iAl tlt; •,j e 4 � 1 Materials of construction: Dimensions Depth of solids e Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): r R h t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 i Commonwealth of Massachusetts 4. ,p Title 5 Official Inspection Form bl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Althea Dr Property Address Dave Rioux Owner Owner's Name information is Cumma uid MA 02637 5-9-19 required for every Q page. City/Town State. Zip Code Date of Inspection D. System Information (cost.) 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 Y1 2 1: 1 r t5ins .doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 P P 9 P Y 9 Commonwealth of Massachusetts .�� Title 5 Official Inspection Form ilk Subsurface Sewage Disposal System form -Not for Voluntary Assessments ' 9 p Y rY 51 Althea Dr Property Address Dave Rioux Owner Owner's Name information is required for every Cummaguid MA 02637 5-9-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope Y ❑ Surface water r ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20' feet Please indicate all methods used to determine the high groundwater elevation: ❑ Obtained from system design plans on record f If checked, date of design plan reviewed: pate ® 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 and town maps show groundwater at greater than 20'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 J Commonwealth of Massachusetts ` Title 5 Official Inspection Form !' I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a T ?°1 51 Althea Dr Property Address Dave Rioux Owner Owner's Name information is Cumma uid MA 02637 5-9-19 required for every 4 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 4 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 5.0fficial Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 MUNS ELL ASSOCIATES CO- HOME INSPECTION SERVICES 3179'MA9'N'STRE"ET`('?T. 6A) 'P.O. BOX 431 10R,NSTAB'LE,.MA�S'SACHVSETTS 026310 (5'08')3'62-40437 fAX(508)362-299'2 ip SU SURFACE S' .WAGE DIS`P'OSAL" SY{S"TEM PE'C'TI'ON FORM Address of property- 51 Althea Drive CI`Mi aquid., 'MA Owner' s Name : Mr. Anthony Altero Date of Inspefction: April 17, 1995 PART A CHECKLIST Check if the follo'w`ing "have been done x Information was' requested of the owner, dccupant, and Board of k-ealth. i x None of 'the s'y'stem components' have 'been pumped f`or at least two weeks and the system has been receiving normal flow rates during that p'eriod. Large volumes of water have not been introduced- into the sys'teTm recently or as part of this insVe'ction. t x As built plans have been obtained and e'xamin`ed. Note if they ar'e` not available with N/A. x The facility or dwelling was inspected -for signs of sewage back-up. x The site was inspected for signs of breakout. x All system conpoients, excluding the SAS, have been located on the site . SAS was located and insgeecte"d. x The septic tank manholes were uncovered, . openied, and the interior of the septic tank wa : ins=pected for cordto'ri of baf f le,s' or te`&o, material of construction, dimens-ions, depth of liquid, depth of sludge, depth of scum. x The size6 and location of the SAS on the site has been determined based 'on the existing: information or approx- imated by non-intrusive methods. x The facility own r (and. occupants, if different from owner) were provided with information on the proper maintenance of SSDS . Page 1 SUBSUR-FACE SEWAGE DIS'P'OS'AL' 'SY'S'TEk INVP''E'C'TT'ON FOkM< PART B SYSTEM INF kMAT'I`ON FLOW CONDITIONS:' If residential - 3 number of b'eAdrddm`s 2 number of di!rre4nt residents s NO garbage' gri'r de'r,� y'e's' or no YES laundry c!onne!c't&d to system, yes dr 'no NO seasonal u9e; y` ,s or no If nonresidential, c°aIddlated flow: N/A Water meter readings', if available: $''10VO Gallons': la�ist 12 mn'ditths! Current I; tst d'at'e of occupancy GENERAL INF'dRMATI'dk,' Pumping records and s�du'rce of informati'dn: No record at the 'town owner indicated he has h`dt head it p'umpe'd. NO System p'u"rnp�e'd as` part of inspe'cti'o`n, yes or no If yes, v'olum6e pumped_N/A Gallons Reason for pumping: N/A Type of System X . Septic 'tank/di-stribution box/soil a'bbsorp'tion system Single cesspool Ove r f 1 ow c`e,sspo'o 1 Privy Shared 'system (ye*s or no) (if yes, attach ,g dVicrus^ insp`edtidn rec'o-rd's', if 'any) Other (Explain)_N'/A Approximate age of all 'comp'dnents. Date installed; if 'k'ndwn. .Source of irifo'rmatidn: Sept 11, 1992 Date `of compliance is'su d, t6Wh r`elcords No Sewage odors detected when arriving at si e, ye-s or no, Page 2 I , r S'UB'SURFACE SEWAGE DISP'dSAL IN'SPECTIOk' FORM PART B S`Y'StEM INFORMATION] c'd—nt'A`esd SEPTIC TANK: Ye's ' (locate on site plan) i� depth below' grade:12 inches front 18 indh6ss re'a`r f material of construction: X concrete rddtal w FRP other (explain)` dimensions : L`=`8'''b" W'= 4 ' 10" D= '5 ' 7'' 41'6" to inlet 1 inch sludge d'e'pth 48 inches; distance from top of slud`ge to bottom of outlet tee or baffle , 6 inches scum thic'kne'ss .8 inches didtanc'e from top of scum to 'top of outlet tee" or baffle _12 inches distance from bottom of 's,cUm to bot`toTft of 'outlet tete or baffle Comments (recommendation fo'r '1 u,Utp�ing, condition o'f inTe't 'a'nd "o`u'tlet tees or baffles, de'p'th of liquid level in relation 'to outlet invert, structural integrity, evidence. of leakage, re6omm`endati=4 for repairs, etc. ) Recommend that the system be pumped nex year. DISTRIBUTION B`OX: YES (locate on site plan) 0" depth of liquid level above outlet invert Comments : (note if level and dis'tribution is equal, evid6tfte of `sfol d"s' carryover, evidence of leakage into or out of bdx, re'commend'ation for repairs, etc. ) None" of 'the above PUMP CHAMB ER:: N/A (locate on site plan) N/A pumps in working order, yes or no Comments : (note condition of p mp 'chamber, condition of pumps and appurte- nances, recommrendati'ons for maintenance or `repairss; e't"c . ) Page 3 L PART B SYSTEM INFORMATIO5 c'on't need SOIL ABSORPTI l SYS'TtM' ''(SAS) : Yeas (locate on site plan, if possible, excavation not required, but may be approximate°d by non-intrusive methods) If not dete'rrmined to be present, explain: w Type leaching pits and number 1 "— ' 'gall'dh, `co'n`c'rete Pit leaching chambers and number leaching galleries and number N/A leaching trenches, number, dimensions N/A overflow ce°s`s:pool, number &/A a comments: .(note conditons . of soil, signs of hydraulic failure, level of ponding, condition 'of vegetation, re'cdrnme`ndations for maintenance or repairs, etc. )' SAS system had about ''6 inches of li4diL in 'b'&ttCiM. Re&cdrrim,4ftd that an extension be installed as the top� 'of the tank is 32; inches below grade . CESSPOOLS (locate 'on site plan) : N/A number number and configuration N/A depth-top of liquid to inlet invert depth of solids' layer depth of scum layer dimensions of c'es'sp0ol materials of co'nstru'c'ti'on indication of groundwater inflow (cesspo'ol must be pumped as part of inspVdtion) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recomme'ntd'a'tons for main- tenance or repairs, etc. ) Privy: N/A (locate on site p°lan) materials of 166nstrudtion dimensions depth of solids Comments : (note condition of soil, signs of hydraulic failure level of ponding, c'onditibn of vegetation, re'''66mrrenda'tions for 'maintenance or repairs, etc . ) Page 4 SUB' 'SbkFACE DISPOSAL SYSTEM INSPE&IO2 'F'O'RM PART B ' SYSTEM INFORMATION doh-tin red SKETCH OF SEWAGE D`IST'US'AL SYSTEM: Y include ties to at least two permanent. refereno'e's° landmarks or benchmarks, locate all wells within 100 ' ------Fl. G"ARA"GE Existing kolisse Front .Of House. S A .-•�. B A-C= 31r 7r► 1000 Gal . C� B,_<C= Septic 1 A-D'= 26 ' 6"' B'-D'= 2`9 ► -- - E A-:E= 32► 7.!► B-E= 27' D=BOX OVERFLOW PIT 8100 G a l. DEPTH OF GROUNDWATER No water at 12 fdot diEp h to g=roundw'ater method of detdrininatic'n or approximation: Observation -pit dug durintg test P-59`07' dated 7/11/'8J6, Page 5 • I 7 t . . SUBSURFACE `SEW'AG'E DISPOSAL S'YS'TE1 I fgS`P�E'C'T'I©'IaT FORM' PART C FAILURE CRITgRIA Indicate yes, no, or n(ot determined (Y',N, `o'r 14 ) Dleecrib'e-basis% of determination in all instances:. If "not determin'ed" , ex.plain . why not) N _Backup of sewage into facility? N Dis`ch`a'rg'e or pbn'didg' of of f luen-t to the surf ace of tY e ground or si rf'ac'e waters? n Static liquid IeVel in the dis`tribu'ti©i -box above `the outlet invert? N/A Liquid depth in cesspool <6'11',,below invert or available volume< 1/2 day flow? N Require'd pumping 4 time's or m'or"e in the last year? number of times pVmp�ed 0 N Septic tank is metal? cracked? struc't'urall.y uns6u id? substantial infiltration? s'ubd-taut al 'e� il'tration? tank failure irrimirieent? Is any portion o`f the SAS, ce's's'p'ool `or privy: N below the high groundwater ele atidn? N within 50 fedt of a surface water? N within 100 feet of a surface water supply or tributary to a surface water supply? N within a Zorie 1 of a public well?' N within 50 feet of a bordering ve`g`et'ated `wietl`andd or salt marsh (c'ess'pools and privies only, no't 'the SAS") N within 50 feet of a private water supply well? N less than 100 feet but greater than 5G feet from a private water supply well with no acc'ep'tab-le water quality analysi-s? If the well has been an'aly'z'dd to be acceptable, attach copy of well water analysis for cdlifortK b4c"teria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. Page 6 L SUBSURFACE SEWAGE DISPOSAL SYSTEM` INS'PEC`'T'ION FORM PART D CERTIFICATION •r Name of Inspector: D!a,rid P. Munsell Company Name : Munsell As'saciates , ; Company Addres's : 3179 Main Street Barnstable, 'MA `026,10 . Certification Statement I certify that I 'have personally ins'pecte`d the sVw44e dis!po'sal system at this address and that the information reported is true, j accurate and dbtple'te as of the time 'of i'ns+p'erc`tion. The inspection was performed and any re`�ebtmeiidat ons regar`din1 up- .grade, maintenance and repair are con `te's2snt with -my training and experience in the proper function and maintenance of do-site sewage disposal systems . `Check one: X I have riot found any information which indicate's that the system fails to adequately pro'tedt public health or the environment as defined in 310 CM'R 15 . 3'03 . Any failure criteria not evaluated are as s't`a red in the FAILURE CRITERIA section of this form. I have determined that the system fails' to' protect public health and the environment as' defined in 3.10' CMR 15 . 303: The basis- for this determination ia provided in the FAILURE CRITERIA section of this form. Inspector' s signature Date : April 18, 1995 Original to sys'te`m owner: Yes Copies to Buyer (if applicable) Approving authority Barnstable Health Vdj artm!6'nt Page 7 l TOW- BARNSTAIBLL . LOCATION SEWAGE#� I :,LAtrfiM :i"t�� f ASSESSOR'S MAP LG'x'_.�: �1NSTAX•L WS NAW 8c>yHOM NO SEg�C TANK{CA3'ACIT'X i LEA 'E'.MG P,AC A-�"Y�; a} �.i. (size}. U a SuiLowt.olk. PERMDATL. �Sepurntiog��9esEenG�Betvree�a tk�ot ,: xlmum�tctjustl Cnau�idwate�TsbtsEo teamtam uirLeec,'htnS Ppclity .,..,, l��ivaic;�tiater 5cip wid LeW i ng Paoi�q► . sny dells Wit all;.; .op,aiw ac wltbsa�Op heat og tonetu9i�!'aciltty) idea tgr c� �leEland s exisE � ivltialtti 30d feat of tCAC�ii{7g�`��t�ry} ,,�� e8 p �Ui gt5hM by /C lrC F A P 1 � - a o O4 3 �- - ®-LI- 33 ` ,�-` - a7' #S� TOWN OF BARNSTABLE j Ci °r LG�CATION SEWAGE # VILLAGE ASSESSOR'S MAP &'LOT 9' INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) /&q-,GA j�a^a�/h (size) NO.OF BEDROOMS BUILDER OR OWNER 1 ) PERMITDATE: t_,/ 7) COMPLIANCE DATE: � R _ Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 a Furnished by Ho Its-�- r1 0 g TOWN OF BARNSTABLE 0 LOCATION 6) SEWAGE # -;Z-=—SO(f G�VILLAGE ASSESSO 'S MAP & LOT G INSTALLER'S NAME & PHONE NO. 7- SEPTIC TANK CAPACITYg�� LEACHING FACILITY:(type) r'7T-- (size) Oa NO. OF BEDROOMS PRIVATE WELL O PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: �z-^luTc.— � DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No�/ �v�`� 3C� 't$� �% z4' ''� � Z�� / Z6--� � 1C� ri l /; THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH P � TOWN OF BARNSTABLE Appliration for Dhipvii l Marks Tunotrnr#inn a'mi# Application is hereby made for a:Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal Sys ..._................ --................... ..... .... L ti AddresJ��, r Lot No. • `�:r:ti1C Sdd .. ner Address a .... .. . ..........- ...... ._ ..................... ..... _....._......._..._. Installer Address ��// Type of Building 3 Size Lot___.�Z-_�_��:'...Sq. feet Dwelling—No. of Bedroomg.-r-___.... ___________________Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ____ U �? No. of persons____________________________ S awers Cafeteria 13 ( ) — ( ) a' Other fixtures .................................. Design Flow..................... . ...............gallons per peas per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity./ .gallons Length_gAi...... Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No---------_--------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing t�% ei '~ Percolation Test Results Performed b :! •.......................... Date........................................ Test Pit.No. l<.a......minutes per inch Depth of Test Pit.................... Depth to ground water........................ w Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water........................ 04 ............. Description of Soil... --_ U --•--•-•--•--•-•-•-•-------••----•-•-••--•-----•--_.... --••••••---•----••--•-•••-•-•-•--•----••-•--••--••---•--•-••---•---•-••-••--•------•••---•......-•--------•-......----•-.._... W x ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•................... U Nature of Repairs or Alterations—Answer when applicable................................................................................................ --------------------------------•--•------------•----------•---------------------------.......--------------...--------------------------------•-----------------•-------------------•••-•-----•----•-•- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code— he under 'gned further agrees not to place the system in operation until a Certificate of Comph e has b u d by oard of health. Signed .... --- --------- - - ------- --..-_:........................................... ........................................ Date Application Approved By ............. ..... .... -.--------- ......... ...............................--------------------- ....................... ..----" Date Application Disapproved for the following reasons: ........................................... .. . --- -- ---------........................................................... .............................................................................................................................................................................................. ---I..................................Dale -. PermitNo- --- -------------- ------ ---------------------------------- Issued ..........................................................------ Dme THE COMMONWEALTH OF MASSACHUSETTS ' . BOARD OF- 'HEALTH { TOWN OF BARNSTABLE Appl ration for Disposal Works Tonotrnrzion 11rrmit Application is hereby made-for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at- 3 J de&�? Lo ati -Addres Lot Na owner Address ---- Iwo - o --------------------- - -------- ✓ Installer Address ! U Type of Building Size Lot__?_ ,66 Sq. feet a /Dwelling—No. of Bedrooms---------_• ------------------------------Expansion Attic ( ) Garbage Grinder ( ) N YP g -- Pe ( ) — Cafeteria Other—T e of Building �-�� No. of rsons____________________________ Showers ( ) Other fixtures ------------------------------------- -------------- - W Design Flow----------------------/.--O-------------gallons per person per day. Total daily flow---------------_-------------___--gallons. WSeptic Tank—Liquid"capacity_IZZ_gallons Length__5x�----- Width---------------- Diameter----------------Depth----_---____ x Disposal Trench—No--------------------- Width--------------------Total Length------------------Total leaching area---------------sq. ft. Seepage Pit No--------------------- Diameter-------------------- Depth below inlet-------------------Total leaching area_-----------sq. ft. H Other Distribution box ( ) Dosing Percolation Test Results Performed by --- --------- - ----. Date --- ------ — - ,,a - MTest Pit No. 1-"*-,.A-•----minutes per inch Depth of Test Pit--------------•_•_- Depth to ground water--_----________----_-___ LLI Test Pit No. 2----------------minutes per inch Depth of Test Pit•-_-_----______-_-- Depth to ground water-----------____----_--_ W - ------------------------------------------------------------------------------- - -- -- --— - O Description of Soil----- __1/ ��-------------------_-------------------- P� V -- 7------ --------------------------------------------------------------------------------------- W V Nature of Repairs or Alterations—Answer when applicable---------------------------------------------------------------------------------------- __-- -------------------------------------------------------------------------------------------------- --- Agreement: A The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—�The undersigned further agrees not to place the system in operation until'a Certificate of Compli na ce has been issued by thAlQrd of health. Signed--- Aj------ ---61----------------------------------------- . ------------------------- Dare A lication Approved B PP PP y ------------------------------------------------------------------------- --------7. Application Disapproved for the following reasons- ---------------------------------------------------------------------------------------------------------------- -------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------=--- Dare PermitNo- -------------------------------- ----------------------------- Issued -------------------------------------------------------------------- Dare THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE (Grtifirz& of 49ompliance HI S=TO CERTIFY, That the Individual Sewage Disposal System constructed ( x ) or Repaired ( ) by------------------------------ - o U _ Gt wv t atfl�'T... ----- l�'[ _-------------- --------------------------------------------------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. _.__.Z�--...._ ------ dated ----____________________________________________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE------------------------- 1OI � Inspector ------------- .. -------------------------------------------------------/ . y THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No..... a:. .�.[j Fim.......Disposal Yorks Tonotrnrtiott Prrmit Permission is hereby granted........;Z./ ------------------------------------------------------------------------------------------------ to Construct >C) or Repair ) an Individual Sewage Disposal System atNo--- ------------------i Q-----. -------------------�=.......... t�S ree� t q� as shown on the application for Disposal Works Construction Permit No.r_ =30C Dated ------ - -------------------•----- �- -- - - V DATE................... -�:�.'�a ------•------------------ ------- Board of Health FORM 36508 HOBBS&WARREN.INC..PUBLISHERS St I =FAMILY .3' .$EC�MS �►1 Wit' vF 2 . .._.GA1?F�AC�E GRIIJ�EtZ i SEPt'l C'::TA 3:30�I Sa 7 A9s 4p) ' "-' •` ' :1�,� . 'I aO ' !�-QLLaIJ , , ; Sty �t+A� b�.l ��.. ��Ea� 16lSpoSQL 'PIT : l= 6,joa �� �¢s�v►�E � �Aweq . (5 T- ALtuEA -D21va- B�7 OM . 5A-.S f GAMMA 1 AQL)I'D i . :`TOTAL "DAIL-Y, r-Ow 330 GAXTO ETER AD No. n733 t. CD t ` Ts+T Po E 1 p C- -7�- + F6= l03 TF=164 0 . ---� ,T 'wcoDLoA� ? ! P V•C �_�. �.:.r _ _ - _.. '• ,. Dv. ._ IOU.=99,5 - pKT rug:.. iu✓. GAL I ' `� �o�a : i. wJ•-- $b;C qfr R4 1 S�rIC 94.3 i�r. ag'1 9 TAR wl t'�T w t'K :.; wA6967,?i.. 9r, 4 MrD C>rl'FI© Pwr 'PV-aFI -- Lor loN : LOAA I�Q��tb PLAN RF�JCE TAT T4E Foa-17,-ATp� ��F1D4V tJ NE2EaN.�LOMT,'LyyS� &ltw l AIE! 5l D>�1J�1� �r' JD I ; C7_Eta? ..TWw OF YABi. f; D 15 :col '(r"O�A'( D •�1JIrt 14,1� �CDOU .Alb,t, �L .. 40 U P6 t l r E fw- X`TF1�L N CIS;-'F7. ►J 1 IS: t�OT-;.;T3A aiE oN :hN 1�41704AEVrI" eke i L EiJGI N EEt-5 `-? 5utz�' MJD TNT �Ft=Sefsrt�t�flUL�. �IDr BE 05'[E2vtu.r-- MASS . WT I ; .., �DySI� �3U�LTJ1� Cv ALF4E/ DPI Ut �EDGr 7- Icy Icy\ 4- p� /Jl,q. lvp . ry.� f i q -98 Lor 31 ���� '°37 �t ��oos� y�1 dot LOT 2� 10q. //0 \� °6 7 P ER "J n'gin '.,. ' Lti ..ar •• �= cu sU ivc,N No. 23733 , PJCKAM A. BAXTER �J r f Vic w