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Home My WebLink About0053 BAYBERRY LANE - Health Bayberry53 _ 0 4 21 Commonwealth of Massachusetts 336 - , Title 5 Official Inspection Form cop,,, - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �. 4D 53 Bayberry Lane ✓ Property Address INJ Jeanne Driscoll Owner Owner's Name information is Cumma uld Q A g MA_ 02637 October_30, 2018 required for every _9 -�� _ 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 A. Inspector Informationfilling out out forms on the computer, use only the tab Patrick T. Sullivan key to move your Name of Inspector cursor-do not Ready Rooter Excva_ting use the return Company Name key. PO Box 89 _ Company Address Forestdale __ MA 02644 _ - City/Town State Zip Code 508-509-0802 S112843__ Telephone Number License Number B. Certification I certify that: I 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 1 have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails _ _October 31, 2018 Inspectors 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.dcc.rev.7126/2018 Title 5 Official Inspection form:Subsurface sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts :._; Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 53 Bayberry Lane Property Address Jeanne Driscoll Owner Owner's Name information is required for-every ummaq C uid MA 02637 October 30, 2018 —_ 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: 2) System S Conditional) Passes: Y ❑ 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;A N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years Id* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration o exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replace, with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass ins1kis ction if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the to 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 Commonwealth of Massachusetts Title 5 Official Inspection Form r- — Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 53 Bayberry Lane Property Address Jeanne Driscoll Owner Owner's Name information is required for every —Cumma uid�— MA 02637 October 30, 2018 page. Cityrrown 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. backup r k❑ Observation of sewage o r g p or ea out o 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 approv of Board of Health): El broken pipe(s) air replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction iyemoved ❑ Y ❑ N ❑ ND (Explain below): ❑ distributio fbox is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): i ❑ 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 t)te Board of Health: ❑ Conditions exist which require f6rther evaluation by the Board of Health in order to determine if the system is failing to protec�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 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 53 Bayberry Lane Property Address Jeanne Driscoll Owner Owner's Name information is required for every ummaq C uid MA 02637 October 30, 2018 — 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: f ❑ 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 tan 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 asses if the;�Ilwater analysis, performed at a DEP certified laboratory, for fecal Y P Y , P rY, coliform bacteria indicates ent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, pro v ded 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.7126/2018 1ille 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 53 Bayberry Lane Property Address Jeanne Driscoll _ Owner Owner's Name information is Cumma uld MA 02637 October 30, 2018 required for every — —� — _ 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 eithe "yes" or"no" to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system s within 400 feet of a surface drinking water supply ❑ ❑ the sys m is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the s stem is located in a nitrogen sensitive area (Interim Wellhead Protection Are —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 i Commonwealth of Massachusetts �� _ .;__ ,�� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 53 Bayberry Lane Property Address Jeanne Driscoll Owner Owner's Name information is Cumma Uld required for every q MA 02637 _ October 30, 2018 page. CityrFown 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)] l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 53 Bayberry Lane Property Address Jeanne Driscoll Owner Owner's Name information is Cummaquid MA 02637 October 30, 2018 required for every page. Cityrrown 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+ GPD Description: Number of current residents: 2 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)): 2016= 126 GPD2017= 113 GPD Detail: Recommend removal of garbage disposal or pump septic tank yearly to avoid excess solids. Sump pump? ❑ Yes ® No Current Last date of occupancy: Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 �. Commonwealth of Massachusetts Title 5 Official Inspection Form r, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 53 Bayberry Lane Property Address Jeanne Driscoll _ Owner Owner's Name --- information is Cumma Uld required for every q MA 02637 October 30, 2018 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 15.208): --- i Gallons per day(gpd) Basis of design flow (seats/person•/sq.ft., etc.).- Grease trap present? ❑ Yes ❑ No Water treatment unit presen . El Yes ❑ No If yes, dischaFges to Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste d-scharged to the Title 5 system? ❑ Yes ❑ No Water meter readiggs, if available: — Last date of occupancy/use: Date -- Other(describe below): 3. Pumping Records: Source of information: Not pumped since new tank install 2015 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 t_ Subsurface Sewage Disposal System Form Not for Voluntary Assessments 53 Bayberry Lane �tr — Property Address Jeanne Driscoll _ Owner Owner's Name information is Cumma uid required for every q _ MA 02637 _ October 30, 2018 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: Septic tank and D-box installed 07/01/2015. Leach pit over 30 years old. Certificate of Compliance on file at Health Dept. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 2 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.7,126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts �. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 53 Bayberry Lane Property Address Jeanne Driscoll _ Owner Owner's Name information is q required for every Cumma uid MA 02637 October 30, 2018 — page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 1 — 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: 11.5' x 6.5' x 5' H-20 1500 gallons Sludge depth: 3 Distance from top of sludge to bottom of outlet tee or baffle 31 1. Scum thickness 2 — 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 13" _ How were dimensions determined? Dip tube and 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.): Inlet and outlet tees in place. Liquid level at outlet invert. Risers bring metal ring and covers to grade under stone. Recommend maintenance pumping within 1 year. i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 53 Bayberry Lane Property Address Jeanne Driscoll Owner Owner's Name — information is required for every Cummaquid MA 02637 October 30, 2018 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 El other(explain): Dimensions: Scum thickness Distance from top of sc m to top of outlet tee or baffle Distance from botto of scum to bottom of outlet tee or baffle Date of last pump g: 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: j 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 �n - ,/ Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 53 Bayberry Lane_ Property Address Jeanne Driscoll Owner Owner's Name - — information is required for every Cummaquid _ MA _ 02637 October 30, 2018 page. CityfTown 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 al m 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.): One inlet, one outlet. No solids carryover. No high water staining over outlet invert. Riser brings poly coverJust below grade.___ t5insp.doc•rev.71'26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System"Page 12 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form — Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 53 Bayberry Lane Property Address Jeanne Driscoll Owner Owner's Name information is Cumma Uld required for every q MA 02637 _ October 30, 2018 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- 12' x 6'w/ stone ❑ 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 Commonwealth of Massachusetts ��- Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 53-Bayberry Lane Property Address Jeanne Driscoll Owner Owner's Name information is Cumma Uld required for every q _ MA 02637 October 30, 2018 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 11. SoilAbsor Absorption System SA p y (SAS) (cont. Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit is double stacked with cover 2" below grade. Liquid level 1.5' below top of lower pit. Some root intrusion in upper pit. No staining in upper pit. Clean stone visible in side wall. No sign of past hydraulic failure. /_,• -- III 12. Cesspools (cesspool must be pumped as,part of inspection) (locate on site plan): Number and configuration / I Depth —top of liquid to inlet invert / Depth of solids layer Depth of scum layer Dimensions of cesspool — Materials of constructi�h — Indication of ground ater inflow El Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7i26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts lip Title 5 Official Inspection Form ),� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments < � 53 Bayberry Lane -t, Property Address Jeanne Driscoll Owner Owner's Name information is required for every Cummaguid MA 02637 October 30, 2018 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, sign f hydraulic failure, level of ponding, condition of vegetation, etc.): 15insp.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 Sewage!3 Subsurface ' Voluntary_ Assessments_ � 53 Bayberry Lane Pioperty Address Jeanne Driscoll Owner — — infonnauonis required for every Curnmaquid MA 02637 Ocbober3O 2018 page. City[Tow State Zip Code Date of Inspection D, System Information (Cont.) ' 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal sysbem, including ties to at least two permanent reference landmarks orhannhmprka. Locate aUweUowhhin10O feet. Locate where public water supply enters the building. Check one of the boxes below: hand-okeh:hin the area below LJ drawing attached separately | \ | ' / ��~ i /r ~ ._- / Commonwealth of Massachusetts �� - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 53 Bayberry Lane Property Address Jeanne_ Driscoll Owner Owner's Name information is required for every Cummaquid MA 02637 _ October 30, 2018 page. City[T'own 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: 2.5 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed. 2015 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: maps.massgis.state.ma.us/oliver.php You must describe how you established the high ground water elevation: Test hole in 2015 determied adjusted ground water 2.5' below base of leach pit. On file at Health Dept. 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 r �eZ Commonwealth of Massachusetts �n p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 53 Barry Lane Property Address Jeanne Driscoll Owner Owner's Name -- information is Cumma Uld required for every q MA 02637 October 30, 2018 page. CityrFown State Zip Code Date of Inspection E. Report Completeness Checklist Com plete 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.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 TOWN OF BARNSTABLE V" " %r" LOCATION . r` !`il I.,.�;n�SEWAGE# _ p VILLAGEC,,,,,.,4C/,�i ASSESSOR'S MAP&PARCEL 3 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY ] LEACHING FACILITY:(type) NO.OF BEDROOMS OWNER PERMIT DATE: ��` �' COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) ! Feet FURNISHED BY oy 6 4Z� No. Fee HE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 'fes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 4plicatiou for Misposal *pstrm Construction Permit Application for a Permit to Construct( ) Repair(;Upgrade( ) WnAn( ) ❑Complete System Individual Components Location Address or Lot No. 53 ner's Name,Address,and Tel.No.c—' t o rr SC�V Assessor's Map/Parcel 3 /rya C Caw► O Installer's Name, Address,and Tel.No. ✓';E� Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms 3 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 Nature of Repairs or Alterations(Answer when applicable) Q 6 ID CS 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 issued by Board of Health. gn b Date ?1 J Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Date Issued No. t Fee 4HEE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN-OF BARNSTABLE, MASSACHUSETTS ftplication for ioispiosat*pstrm Construction Vermit Application for a Permit to Construct(. ) Repair(/Upgrade( ) n( ) ❑Complete System �Individual Components Location Address or Lot No. �( wner's Name,Address and Tel.No.c./� �� `0�\ rlm 5 .k <Cp1 53 �. �r,..r.. � 3 53.A Assessor'sMap/Parcel rya f✓,�,� S Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. ``Type of Building: Dwelling No.of Bedrooms 3 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. Descr ption of Soil Nature of Repairs or Alterations(Answer when applicable) 0 J _ (4 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 issued by t is Board of Health. gn ) Date G I. Application Approved by i i�/~ Pffff P Date VV Application Disapproved by Date y for the following reasons S Permit No. Date Issued i ------------------------------------ ------ ---------- - -------- -- - - , - -- -- - - - - Tfi E COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( vl" Upgraded( ) Abandoned( )by ��— O� �,�� r 'C kL v5�"V�n G at S3 t.. has been cons cted in acco d i with the provisions of Title 55 and the for isposal System Construction Permit No.C¢ ,/ e Installer��,o QQ, ,�y�� _he, Designer #bedrooms �_ Approved design flow (1 gpd The issuance of is I ermit shall not be construed as a guarantee that the system wi functi ni J designed. Date 7 1`1 { Inspector D k No. � -----/ Fee ►/ .!/ C/ `� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposa'i 6pstem Construction j3ermit Permission is hereby granted to Construct( ) Repair( %..,< Upgrade( ) Abandon System located at i� and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Constr3ictio must b comp ee ed within three years of the date of this permit. Date U �� Approved by / Town of Barnstable Barnstable Regulatory Services De artment "'"e`CeC`" ^� r Public Health Division s6 0 Q7 39• A'fD'A°y` 200 Main Street, Hyannis MA 02601 zoos Office: 508-862-4644 Richard.V.Scali,Director. FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL #7014 1200 0001 0358 3339 May 14, 2015 William Driscoll . 53 Bayberry Lane . Barnstable, MA 02637 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5 • The septic system located at 53 Bayberry,Barnstable, MA was last inspected on 4/27/20151 by James D. Sears a certified septic inspector for the Sate of Massachusetts. The inspection of the septic system showed that the system"Fails"-under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following: O Any portion of the SAS, cesspool, or privy below high groundwater elevation. You are ordered to repair or replace the septic system within one (1) year from the date you receive this notification. Failure to repair/replace the septic system with the deadline period will result in future enforcement action. PER ORDER OF HE BOARD OF HEALTH Thomas McKean, R.S., CHO. Agent of the Board of Health , • Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\53 Bayberry Ln Barns May 2015.doc INN T " Town of Barnstable i + SA STARM Regulatory Services Department 'OTfD MAC� , Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007. Rev. 4/28/15 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR-15.000) An"X"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1) YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due.to an overloaded or clogged SAS or cesspool )<Any portion of the SAS, cesspool, or privy below high groundwater elevation . ❑ Any portion of the cesspool within a Zone.1 to a public well ❑ Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any "conditionally passed systems" (broken cover, relocation of a pipe, relocation of a driveway due to H-10 components, etc) ❑ Leaching pit or cesspool with high liquid level, <1.2" below pit (per Town Code §360-9.1) OTHER ❑ 6 Repair deadline: Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc r lay 03 15 09:20p p.1 - Commonwealth of Massachusetts 5 Title Official, O �cial Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 53 Bayberry Lane Property Address William Driscoll Owner Owners Name information is required for every Barnstable MA 02637 4-27-15 page. Cityfrown 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 A. General Information filling out forms �,�UuuunlN! 44 use only hon the computer, tab ``��` I4tOFl �i��'�� key to move your 1 Inspector: / r 11 y. cursor-do not James D.Sea �a "" / z6? J ES yu' use the return _ AM :m may. Name of Inspector s . �* _ CapewideEnterprises,LLC o VQCompany Name r ••.RTIF .� 153 Commercial Street Company Address _Mashpee MA 02649 Cityrrown State Zip Code 598A77-8877 S 1623 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 16.000).The system: ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Local Approving Authority n-�-� 5-1-15 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 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. •P S/Cp�et O/J r 151re•3f13 �� Tdle 5 Official Inspection Form,SubpFfece Sewage Disposal Syslem•Pape 1 of 17 .F'i j ps A s May 03 15 09:20p p.2 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments •''< 53 Bayberry Lane Property Address William Driscoll Owner Owner's Name information is required for every Barnstable MA 02637 4-27-15 page. Cityrrown State Zip Code Dale 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: Failed system., The system is a 1000 Gal.Tank D Box and Pit. 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-3113 Title 5 Or@dal Inspeefioa Fart Subsurface Sewage Disposal System•Page 2 of 17 May 03 15 09:20p p.3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 53 Bayberry Lane Property Address William Driscoll Owner Owner's Name information is Barnstable required for every MA 02637 4-27-15 page. City/Town State Yip Code Date of Inspection B. Certification (cunt.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cunt.): ❑ 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 0 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 6ns•3113 . Title 5 Mdal Inspection Fortn:subsurface Sewage Oisposel System•Page 3 of 17 May 03 15 09:21 p p.4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments _ 53 Bayberry Lane Property Address William Driscoll Owner Owner's Name information is MA 02637 4-27-15 Barnstable required for every ._ page. Cityrrown State Zip Code Date of Inspection B. Certification (cunt.) 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. Q 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 Ail 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 dogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or dogged SAS or cesspool ❑ ® Liquid depth in 101411101111 is less than 6"below invert or available volume is less than'/day flow 4i7— i51ns•3113 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 4 of 17 May 03 15 09:21 p p.5 Commonwealth of Massachusetts �a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 53 Bayberry Lane Property Address William Driscoll Owner Owners Name information is required for every Barnstable MA 02637 4-27-15 page. citylrown 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- El ® 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 0 the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 off 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 TICS 5 Offidal 11spection Fwm Subsurface Sewage Disposal System Page 5 of 17 May 03 15 09:21 p p.6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 53 Bayberry Lane Property Address William Driscoll Owner Owners Narne information is required for every Barnstable MA 02637 4-27-15 page. Cdyrrown 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 NIA) ® ❑ 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)1310 CMR 15.302(5)] D. System information Residential Flow Conditions: Number of bedrooms(design): NA Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 451ns-311.3 Title 5 Official Inspection Form:QbsuKnoo Sowage Disposal Sntem-Page 6 or 17 May 03 15 09:22p p.7 commonwealth of Massachusetts _ Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 53 Bayberry Lane Property Address William Driscoll Owner Ownees Name information is required for every Barnstable MA 02637 4-27-15 page. Citylrown State Zip Code' Date of Inspection D. System Information Description: The system is a 1000 Gal.Tank D Box and Pit Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 2013-99,000Gals Detail: 2014-99,000Gal's Sump pump? ❑ Yes ® No Last date of occupancy: Present Date Commercial1industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/personsisq.ft., etc.): Grease trap present? Q 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: !Sins-3/13 7rtle 5 Ofrie inspe&on Form:Subsurface sewage Disposal system•Page 7 of 17 May 03 15 09:22p p,8 s , Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y` 53 Bayberry Lane Property Address William Driscoll Owner Owner's Name information is required for every Barnstable MA 02637 4-27-15 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: 08-10-13 Was system pumped as part of the inspection? El 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 Q Shared system(yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Aitemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the l/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3113 Title 5 Oftidal Inspection Form:Subsurface Sewage Disposal System•Page 8 or 17 May 03 15 09:22p p.9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 53 Bayberry Lane Property Address William Driscoll Owner Owner's Name information is Barnstable required for every MA 02637 4-27-15 page. Cityrrown State Zip Code Date of Inspection D. System information (cont.) Approximate age of all components, date installed (if known)and source of information: Tank& Box NA-Pit around 1975 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC r® other(explain): -Distance from private water supply well or suction line: .feet Comments(on condition of joints, venting, evidence of leakage, etc.): Pipeing is PVC &Orange Burge Septic Tank(locate on site plan): Depth below grade: 14" feet Material of construction: ®concrete ❑ metal ❑ fiberglass ❑ polyethylene Q 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. Precast H-10 Sludge depth: 211 t5irs 3113 Tde 5 OWdW Inspection Form:Subsurfaw Sewage Disposal system•Page 9 D117 May 03 15 09:23p p.10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 53 Bayberry Lane Property Address William Driscoll Owner Owner's Name information ruire n twn is required for every Barnstable MA 02637 4-27-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 1 T How were dimensions determined? Asbuilt-Tape _Sludge Judge 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 at working Ievel.'Tank and inlet i over'at 14"below glade w1out let cover steel at grade. Outlet Baffle. No sign of leakade or over loading Note: H- 10 Tank in stone drive way Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene y ❑ 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 tsins-3M3 Tale 5 Dtricial Inspection Form Subsurface Sewage Disposal System•page 10 of 17 May 03 15 09:23p p.11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 't 53 Bayberry Lane Property Address William Driscoll Owner Owner's Name information is required for every Barnstable MA 02637 4-27-15 page_ City/Town State Zip Cade 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 p )( cate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal El fiberglass ❑ polyethylene El 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.): y Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No tSns a;13 Title 5 Official Inspection Fow Subsurface Sewage Disposal System-Page It of 17 May 03 15 09:23p p.12 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 53 Bayberry Lane Property Address William Driscoll Owner Owner's Name information is required for every Barnstable MA 02637 4-27-15 page. Cityrrown 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.): iD Box is 15"x21"-22". Below Grade. Wairs are gone on D Box� t Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ NW 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 Tits 5 Officiat Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 May 03 15 09:24p p.13 2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 53 Bayberry Lane Property Address William Driscoll Owner Owner's Name information is required for every Barnstable MA 02637 4-27-15 page. C4 Town 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/altemative system Type/name of technology: — Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): Leaching is a 1000 Gal. Pit w/a 1000 Gal. Piton top. Piped into tapper pit Lower pit water level at 1'from top. Cover at 10". Bottom of pit in ADJ. High G W need to replace leaching Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No 15iru-3113 Title 5 Othdel Impedion Form:Subsurface Sewage Disposal System•Pape B of 17 May 03 15 09:24p p.14 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments •' 53 Bayberry Lane Property Address William Driscoll Owner Owner's Name information is required for every Barnstable MA 02MY 4-27-15 page. City/town 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 at 17 E . May 03 15 09:24p p.15 commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 53 Bayberry Lane Property Address William Driscoll Owner Owner's Name required far every is Barnstable MA 02637 4-27-15 required page. Cdylrown 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 -I= � �� REAR A - o 7 13 o t5ins•3113 7iUe 5 Official Inspection Form:Subsurface SSWO90 Disposal System-Page 15 e`r7 Mhy 03 15 09:25p p.16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 53 Bayberry Lane Property Address William Driscoll Owner Owners Name information is required for every Barnstable MA 02637 4-27-15 page. CltylTown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: [] Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water. 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: see below ❑ Checked with local excavators, installers-(attach documentation ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: G.W.off Town Map& T.H. at 25 Bayberry Ln.. T.H. 10-31-13 G.W.at 12'w/ADJ. at 9' Note: Bottom .of pit at 14' below grade. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Olfioal Ins pection Form Subsurface Sewage D'bposal System•Page 16 of 17 May 03 15 09:25p p.17 .� Commonwealth of Massachusetts . �.i Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 53 Bayberry Lane Property Address William Driscoll Owner Owner's Name id is require fbr every Barnstable MA 02637 4-27-15 page. CityfTown 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 Serge Disposzd System-Pape 17 of 17 Town of Barnstable Office: 508-86.2-4644 Fax: 508-790-6304 Regulatory Services Department BA _ 4BM Public Health Division v , Thomas A.McKean,CHO 200 Main Street, Hyannis, MA 02601 Payment Receipt Septic Inspection Payment received: 2$ 5.00 (Check) on 5/6/2015 Permit number: 10831 E i ;Check number: 32366 Check amount: $50.00 Name on check: Capewide Enterprises, LLC :;Owner: JEANNE A DRISCOLL ;Address: 53 BAYBERRY LANE, Barnstable } i i 4 Town of Barnstable : P# R7�1 Department of Regulatory Services +;M I F Public.Health Division Date I➢• � 200 Main Street,Hyannis MA 02601 Date Scheduled = uTime Fee Pd. i Sail�Suitabrli j r ty Assessment for Se ag Disposal Performed-By:. 1 \ n Witnessed By: vt oC� 1 LOCATION& GENERAL INFORMATION l Location Address ' \ yr,rN.P�, 4�.e owner's Name Address Assessor's Map/Paroel: " 3� C tJ " �``�v'� o20J 1� F O4 Engincer'a Name M��,J a�3 1.,S�—=A NEW CONSTRUCTION REPAIR Telephoneli' Land Use• �� / Slopes(%) Surface Stones Distaricea Item: Open Water Body ft Possible Wet Area77 R Drinking`WatcrWell . {t _ Draiha a We r g Y ft Property L'Irie —___R . Other ft J • 00I "TCH:(Street name,dimensions of lot,exact iocatlons of test holds&pern testa,locate wetlands in proximity to holes) - r Parent material(geologic d'r Depth to Bedrock Depth 10 Groundwater. Standing Water In Hole:— l• N Weeping iVom Pit Fnae Estimated Seasonal High Groundwater t w 1' 5 E DEP.,NATION�OR SEASONAL HIG)l WATHA TAKE Method Used:, � ►N�,,I$i�® Dpth Observed standing in obs.hole: 2.�� y Dc{ith to weeping from side of obe:hole: +� In, Deptli to soil InUttles: A— Index Wei►lr — Ill. GroundwaterAdjunment• 1 Reading Date: Index Well level —= • AcU,'ttlCtbr AcQ_ 1-oundwaurIevel, [Depth bservation PERCOLATION TEST Dais—_ rhlnte ole# Tlnte at 9" of Pere Time at G" Start Pro-soak Tlme End Pre-soak _ Rate Min./Meh Site Suitability Assessment: Site PasseR Site Failed: { Additional Testing Needed(Y/N) Original. Public Health Division Observation Hole Data To Be Completed on Back---' ***If percolation test is to be conducted within 100' of wetland,you must first notify the �Barnstable Conselr vntion Division at least one(1)week prior to beginning. Q:ISEPTIC\PERCFORM.DOC ��j DEEP-OBSERVATION HOLE LOG Hole# Depth from Sell Horizon Soil Texture Shcl Color 9011. Other Surface(In.) (USDA) (Munsell) Mottling (Stnuchire,Stones;Boulders. Vi r si to cy,%•Gravel) 3S"- il'i t�'r s , aoti'1��.3� �-� N��•®Si 2_57Y (y DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color. Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, a Ott l o s 61 it D`I-�IN 5ILT Lo tm •l0•'1 P-IL, )o`"- 1341 Cq M e.V S*r4 �.�y?jq DEEP OBSERVATION HOLE LOG Hole# � Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Muuscll)'-,' Mottling (Structure,Stones,Boulders. Consistancy, DEEP OBSERVATION HOLE LOG Hole# ri Depth from Soil Horizon Soil Texture Sell Color Soli Other t Surface(in.) (USDA) '�"r(Muns_ell) Mottling (Structure,Stones;Boulders, Consistancy, i Flood Insurance Rate Map: Above 500 year flood boundary No Yes.. l Within 500 year boundary No v+ Yes ' YWithin L00year flDori boundary ryNo.� — ..._..__es Depth of Naturally Occurring Peryioue Material Does at least four feet of naturally occurring pe aterial exist in all areas observed thrpughout the area proposed for the soil absorption system? M w. 'ZOO 7--&4 If not,what is the depth of haturally occurring pe ious material's . Certification �^ [� I certify that on LO (date)I have passed the soil evaluator examination approved by the Department of Environ ental Protection and that the above analysis was performed by me consistent with . the required t ng peruse and experience described in 10 CUR 15.017. )A-A I Signature Date 7-3 i Q.\SHI" 0PHRCPORM.DOC cop Commonwealth of Massachusetts I�VI P Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 53 Bayberry Lane Property Address William Driscoll Owner Owner's Name information is Cum quid MA 02637 07/02/2015 required for every page. Citylrown 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 A. General Information filling out forms on the computer, `-7/ /0 �lf use only the tab 1. Inspector: c� key to move your cursor-do not Patrick T. Sullivan use the return Name of Inspector key. Ready Rooter Excavating _ Q Company Name P.O. Box 89 Company Address Forestdale MA 02644 City/Town State Zip Code 508-888-6055 S112843 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 07/02/2015 Inspector's Signature — Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3113 p Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 53 Bayberry Lane Property Address William Driscoll Owner Owner's Name information is Q required for every Cumma uid MA. Q2637 07/02/2015 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: New H-20 tank and d-box installed 07/01/2015. 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 inspec on 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 ❑ D (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M •' 53 Ba ber Lane Y ►Y Property Address William Driscoll Owner Owner's Name information is required for every Cummaquid MA 02637 07/02/2015 page. Citylfown 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 level or replaced ❑ Y ❑ N ❑ ND (Explain below): i ❑ 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): 1 ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): i ❑ 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 53 Bayberry Lane Property Address William Driscoll Owner Owner's Name information is required for every Cummaquid _ MA 02637 07/02/2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. / ❑ The system has a septic tank and/SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply/well". Method used to determine distance: ** This system passes if the weI�ater analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. i 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M .' 53 Bayberry Lane Property Address William Driscoll Owner Owner's Name information is q required for every Cumma uid MA 02637 07/02/2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails.. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400,feet of a surface drinking water supply i i ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is locatedin a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or mapped Zone II of a public water supply well If you have answered"yes" to any qu stion in Section E the system is considered a significant threat, or answered "yes" in Section D abo ie the large system has failed. The owner or operator of any large system considered a significant t/hreat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 53 Bayberry Lane Property Address William Driscoll Owner Owner's Name information is q required for every Cumma uid MA 02637 07/02/2015 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 GPD t5ins•3/13 Title 5 Official Inspection Form: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 53 Bayberry Lane Property Address William Driscoll Owner Owner's Name information is required for every _Cum_mq uid MA 02637 07/02/2015 ._ 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 ears usage d 2013= 110 GPD g ( y g (gp )) 2014= 98 GPD Detail: Sump pump? ❑ Yes ® No Last date of occupancy: CurrentDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/esent? .ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding ta ❑ Yes ❑ No Non-sanitary waste disscchaTitle 5 system? ❑ Yes ❑ No Water meter reading, if available: t5ins•3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 53 Bayberry Lane _ Property Address William Driscoll Owner Owner's Name information is required for every Cummaquid MA 02637 07/02/2015 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: New tank installed 07/01/2015 Was system pumped as part of the inspection? ❑ Yes ® No I 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 Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 53 Bayberry Lane Property Address William Driscoll Owner Owner's Name information is required for every Cummaguid MA 02637 07/02/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information.- Septic tank and d-box installed 07/01/2015. Leach pit installed appox 1984 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: n/a feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 1 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: 10'8"X 67'X 5'10" H-20 1500 gal -- Sludge depth: 0 I5ins•3I13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 53 Bayberry Lane Property Address -- - William Driscoll Owner Owner's Name information is required for every Cummaquid MA 02637 07/02/2015 page. City/Town 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 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 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.): Inlet and outlet PVC tees in place. H-20 tank has metal ring and covers to grade in driveway area. Recommend pumpin.. every 2 years for maintenance. 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 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 53 BaybehrvLane Property Address - — — William Driscoll Owner Owner's Name information is required for every Cummaquid MA 02637 07/02/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cost:) 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.- El concrete ❑ metal ❑ 'berglass ❑ 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 L,5,ns3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 53 Bayberry Lane Property Address -- William Driscoll Owner Owner's Name information is required for every Cummaquid MA 02637 07/02/2015 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 11 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.): One inlet, one outlet. New H-20 D13-3 just installed. 18" PolyLoc cover 2" below grade. Secured w/3, 1/4" hex screws. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump cham er, 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 53 Bayberry Lane _ Property Address William Driscoll Owner Owner's Name information isequired for every Cumm—a uid MA 02637. 07/02/2015 page. CityrTown State Zip Code Date of Inspection D. System Information (cont.) Type: 1- 12'D X 6'W w/® leaching pits number: stone ❑ 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.): Double stacked leach pit. Liquid level 2' below top of lower pit at time of inspection. No sign of staining in top pit. Clean stone visible all the way up. Cover is 6" below grade. 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 53 B ybe�Lane Property Address William Driscoll Owner Owner's Name information is required for every Cummaquid MA 02637 07/02/2015 page. City/Town 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 53 Bayberry Lane Property Address William Driscoll Owner Owner's Name information is required for every Cummaguid _ MA 02637 07/02/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately FU J 1. I I I t5ins•3112. Tide 5 Official bu on Form:Subsurface Se wage swage Disposal System•Page 15 or 17 Commonwealth of Massachusetts Y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 53 Bayberry Lane_ Property Address — — William Driscoll Owner Owner's Name information is required for every Cummaquid MA 02637 07/02/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 2.5 below base of SAS 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: 06/15/2015 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: maps.massgis.state.ma.us/oliver.php You must describe how you established the high ground water elevation: Test hole performed on June 15, 2015 found ground water at 19.5'. Adjusted ground water at 17.4'. Base of leach pit at 14.5'. See attached "Determination for Seasonal High Water Table" Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 53 Bayberry Lane Property Address — William Driscoll Owner Owner's Name information is required for every Cummaguid MA 02637 07/02/2015 page. CitylTown 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