HomeMy WebLinkAbout0035 COUNTRY CLUB DRIVE - Health 35 COUNTRY CLUB DR., CUMMAQUID
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Commonwealth of Massachusetts ( a' z
Title 5 Official Ifispection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c
35 Country Club Drive
Property Address
Ann Garrahan t y
Owner O
wner's Name
information is Cummaquid
required for every MA 02675 6-24-19 ry .
page. City/Town State Zip Code Date of Inspection C°9
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.
"M�UH OF tM
Important:When A. Inspector Information pr�
filling out forms p '�`�� '•••.•... '' .9�'y-.
on the computer, 4 ' JAMES rt,'
use only the tab James D.Sears z• ; _
key to move your Name of Inspector __ :
cursor-do not Jim The Inspector Man �'•.o o:
use the return
key. Company Name (F •.. •• 'G ��.`
P.O.Box 784 S INBF�C
' mtitnruua���`
Company Address -
West Yarmouth MA` 02673
City/Town State Zip Code
�suan 508-364-4398 S1623
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 I have determined
that the system: -
1. ® Passes F
2. ❑ Conditionally Passes -
3. ❑ Needs Further Evaluation by the Local Approving Authority ,
4. ❑ Fails
6-25-19
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
Title 5 Official Inspection Form
i; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
35 Country Club Drive
Property Address
Ann Garrahan '
Owner Owner's Name
information is required for every Cummaguid MA 02675 6-24-19
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:
r •
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below. '
Comments:
The system is a 1500 Gal.Tank D Box and four chambers. -
2) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not_determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection"if the existing tank is replaced with a complying septic tank as approved by the Board of
'Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
F
❑ Y ❑ N ❑ ND (Explain below):
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P
Commonwealth of Massachusetts
I'F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
35 Country Club Drive
Property Address
Ann Garrahan
Owner Owner's Name - -
information is required for every Cummaquid MA 02675 6-24-19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static'water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ 'broken pipe(s)are replaced - ❑ Y ❑ N ❑ NDI"(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health: '
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.•
a..System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
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P
Commonwealth of Massachusetts
Title 5 Official Inspection Fore
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
35 Country Club Drive
Property Address "
Ann Garrahan
Owner Owner's Name '
information is Cumma uid MA 02675 6-24-19
requiredd for every q
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:
J
❑ 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: ,
i
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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
\V 35 Country Club Drive
Property Address
Ann Garrahan
Owner Owner's Name
information is
requited for eve ryCumma uid MA 02675 6-24-
19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cost.)
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 is less than 6" below invert or available volume is less
than '/z day flow TEXPI-W4
❑ ° ® 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 servinga facility with a design flow of 2000 d-
Y 9 9P
® 10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.-
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection ,
Area— IWPA)or a mapped Zone II of a public water supply well
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
35 Country Club Drive.
Property Address
Ann Garrahan
Owner Owner's Name
information is Cummaquid. MA M675 6-24-19
required for every '
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?
El ® 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:
Z, ❑ Existing information. For example, a plan at the Board of Health.
Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
g� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
• �� 35 Country Club Drive
Property Address
Ann Garrahan
Owner Owner's Name
information is
Cumma uid MA -
02675 6 24-19
required for every q _
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): _- 330
Description:
1500 Gal. Tank D Box and four chamber's.
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
-
Doe's 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.) n
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter usa e readings, if available last 2 ears d 2017-146,000Gal
.g ( Y g �9p ))' 2018-144,000Gal's
Detail: '
Sump pump? ❑ Yes ® No
Last date of occupancy: NA
• Date
15insp.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
J� Subsurface Sewage Disposal System Form Not for Voluntary Assessments
35 Country Club Drive
Property Address
Ann Garrahan
Owner Owner's Name
information is required for every Cummaquid MA 02675 6-24-19
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: NA
Was system pumped as part of the inspection? ❑ Yes ® No
If y`es,�volume pumped: gallons
i 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
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Vol untarylAssessments
35 Country Club Drive
u� Property Address
Ann Garrahan
Owner Owner's Name
information is Cummaquid MA 02675 6-24-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
K 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:
1998 Permit#98-580
-Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
4 3811
Depth below grade: feet'
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: ` - feet
Comments (on condition of joints, venting; evidence of leakage, etc.):_
Pipeing is 4" PVC SCH -40. '
t5insp.doc•rev.7/26/2018 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
35 Country Club Drive
Property Address
Ann Garrahan
Owner Owner's Name
information is Cumma uid MA 02675 6-24-19
required for every q
page. City/Town State Zip Code Date of Inspection
D. System Information (ccnt
6. Septic Tank (locate on site plan):
Depth below.grade: 28"
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
o
Dimensions:
1500 Gal Precast H-10
Sludge depth: `
Distance from top of sludge to bottom of outlet tee or baffle
' 29"
Oil
Scum thickness
.. _ 811
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
18"
How were dimensions determined? Asbuilt-Plan=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 level. Tank at 28" below grade w/both covers at 10". In and out tees. No sign of
leakage or overloading.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts.
Title 5 ®fficiaa Inspection Form
4 -
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
p Y
35 Country Club Drive
Property Address "
Ann Garrahan
Owner Owner's Name
information is required for every Cummaquid MA 02675 , 6-24-19
page. City/Town State Zip Code . , Date of Inspection
D. System Information,-(Cont.)
7. Grease Trap (locate on site plan): „
Depth below grader ry feet
Material of construction:
❑ concrete ❑:metal ❑'fiberglass El polyethylene El 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.):, ' x
y
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): '
Depth below grade: # a
Materia[of construction: -�
:concrete ❑ metal ❑'.fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
v " gallons
Design Flow:
gallons per day
t5insp.doc-rev.7/26/2018 " a Tide 5 official Inspection Form:Subsurface Sewage Disposal System-Page 11 of.18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
!% 35 Country Club Drive
V
Property Address
Ann Garrahan -
Owner -
Owner's Name ,
information is Cummaguid MA 02675 6-24-19
required for every .
page. City/Town State `Zip Code Date of Inspection
D. System Information (cone.)
8. Tight or Holding Tank (cost.)
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 inveit 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.):
D Box is 16"x16"-3'-4" below grade w/one line out. Box is clean and solid w/no sign of over loading
or solid carry over.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
P _
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
tl� 35 Country Club Drive
Property Address
Ann Garrahan
Owner Owner's Name
information is Cumma uid
required for every 4 MA 02675 6-24-19
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:
® leaching chambers number: 4
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
f
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurfacew Sewage Disposal System Form Not for Voluntary Assessments
35 Country Club Drive r
Property Address
Ann Garrahan
Owner Owner's Name -
information ation is Cummaquid MA 02675 6-24-19
required for every
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.):
Leaching is four cultec(330)W/4'stone. Camera out and prob.area..No sign of over loading or
holding water.
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
A
Commonwealth of Massachusetts
I
Title 5 Official Inspection Form
Iol Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
v
35 Country Club Drive .
Property Address
Ann Garrahan
Owner Owner's Name
information is required for every Cummaguid MA 02675 6-24-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.): `
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 official Inspection Fora
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
.;, 35 Country Club Drive
Property Address
Ann Garrahan '
Owner Owner's Name
information is required for every Cummaguid MA 02675 6-24-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building; Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
A ,
Commonwealth of Massachusetts "
p Title 5 Official' Inspecition Form
b Subsurface Sewage Disposal'System Form Not for Voluntary Assessments.
35 Country Club Drive
Property Address ,
Ann Garrahan `
Owner Owner's Name
information is Cumma uld
required for every 4 MA a .,02675 ,. 6-24-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cost.)` -
15. Site Exam:
❑ Check Slope'
Surface water 1
Check'cellar.
❑ Shallow wells' s
Estimated depth to high groundwater: '26
feet
Please indicate all methods used to determine the high'ground°water elevation:
El
Obtained fromsystem design plans on record
If checked;date of design plan reviewed: '
Date
" Observed site(abutting propert&bservation hole within 150 feet of SAS)
❑ `. Checked with,local Board of Health -explain: -
Checked with local excavators,.installers, (attach documentation) "
® Accessed USGS database -explain: ,
U.S.GS.•well AIW 247.
You must describe how-
wryou established the high ground water elevation:
U..S.G.S. well AIW 247 at 26 w%ADJ at 20'. Bottom of chamber's at 4"below grade. Bottom of
chamber's.at 16' above ADJ High G.W..
}
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 o Page 17 of 18
f
Commonwealth of Massachusetts
Title 5 Offici
al cial Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
35 Country Club Drive
Property Address
Ann Garrahan
Owner Owner's Name
information is required for every Cummaquid MA 02675 6-24-19
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
4.
®' 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
�01/lorM (of
C/4omaf,?r
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
a'
e
TITLE 5
OFFICIAL INSPECTION.FORM.=NOT.FOR VOLUNTARY ASSESSMENTS
SUBSURFACE`SEWAGE-DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 7 l® �
l_1Q/)yt/��t�LlaT 711.d/�_
Owner's Name:
Owner's Address:
"A 0060
Date of Inspection:..
Name of Inspector please print) b 91
Company Nam , �LlJ�,q&,Ac °
Mailing Address: e `70 V 9(15
Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal:system at this address and that the information reported
below is true accurate and complete as of the time of the inspection. The inspection was performed based on my
P P
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_ k
Need urt er Evaluation by the Local Approving.Authority,
/Fai
Iitspectr'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.
Notes and Comments.
****This report only'describes conditions at:.the time of inspection acid under the conditions of use at that `
time. This inspection does not address how the system will perform in the future under the same or different
-
conditions of use.
Title 5 Inspection Form 6/15/20.00 page 1
Page 2 of l 1
OFFICIAL'INSPECTION FORM—.NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: � �
Owner . .
Date of Inspection: lo o /
Inspection Summary: Check A,B',C,D or E/ALWAYS complete all of Section D,
A. System Passes:
I have not found any information which indicates that any of the failure criteria.described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any.failure criteria not evaluated-are indicated.below. .
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional-Pass,"section:need to be replaced or
repaired.The system,upon.completion of the replacement or repair; as approved by the Board of Health,Will.pass.
Answer yes,no or not determined(Y,N;ND)in the for the following statements. If"not determined"please
explain.
The septic tank is;metal and over 20 years old* or the septic tank(whether metal or not)is structurally,
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent:System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of.sewage backup or break out or high static water level in the-distrib°ution.box due to.broken or
obstructed pipe(s)or due to a broken,'settled or uneven distribution box.System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than'4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2.
Page 3 of I I.
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
. N
SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A `
CERTIFICATI.ON(continued)
Property Address:
Add
P Y
Owner: r
Date of Inspection: 0 J
C. Further Evaluation is Required by the Board.of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless,Board of Health de.ter►niHes in.accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a mariner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water f'
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any),:deteripines.that the
system is functioning in a manner that protects the public health,safety and envirounienti
_ The system has.a septic tank and soil absorption system(SAS)and the SAS.is within 100 feet ofa
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 I 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 froni.a.,
private water.supply well". Method used to determine distance.
**This system passes if the well water analysis,performed at a DEP certified.laboratory,for coliform
bacteria and volatile organic compounds indicates that the welt is free from pollution from that facility and
tl:e preseiace of.arnYiaonia:ritragcn and.nitrate nitrogen a_equalao;pr.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:
3
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A .
CERTIFICATION(continued)
Property Address: _ "22ta
nn
Owner: °J
Date of inspection:_,/6411/01
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
_ J Discharge or pond ing of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number '
off 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 l of&..public well.
Any portion of a cesspool or privy is within 50 feet of&.private water supply well.
_J 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 PEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facilityand 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 att ache ddto this form.]
JA O (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15:303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to.correctthe failure.
E. Large Systems:
To be considered a large system the system mustserve a facilitywith a design flow of 10,000.gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
_ — the system is within 400 feet of a.surface drinking water supply
— _ the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The.system owner should contact the appropriate regional office of the Department.
4
G -
Page 5 of l 1
OFFICIAL. INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE.SEWAGE`DISPOSAL SYSTEM INSPECTION FORM
PART 1$
CHECKLIST
Property Address:
0,
Owner:(24&
Date of Inspections
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)
—le _ 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? r
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:
Yes no
�/. Existing information. For example, a plan.at the Board of Health.
_V Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [31.0 CMR 15.302(3)(b)]
5
Page 6 of 1]
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL:I SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
% r
Property Address: ����
jf
A
Owner:�ejbyadCie
Date of Inspection: doh)j& .
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):-3 Number of bedrooms(actual):
DESIGN flow based on 310 C R 15.203 (for example: 11.0 gpd x#of bedrooms):
Number of current residents:
Does residence have a garbage grinder(yes or no),-�
Is laundry on a separate sewage system(yes or n02p [if yes separate inspection requiredl
Laundry system inspected(yes or notalb-
Seasonal use: (yes or no):, Q`
Water meter readings, if vat ilable(last 2 years usage(gpd)):
Sump pump(yes or n � �cG �cl
Last date of occupancy:
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR I5.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):=
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system (yes or no):
Water meter readings,if available: .
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection yes or no):_
If yes,volume pumped: gallons--How was,quantity pumped determined?
Reason'.for pumping:
TYU OF SYSTEM
Septic tank, distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
_Shared system(yes or no)(if yes, attach previous inspection records, if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy'of the DEP approval
Other(describe):
proximate a e of all coin on nts,d to inst la d(if kno )and source of informa Rio/7lJ�'•
e--
Were sewage odors detected when arriving at the site(yes or no): h
6
Page 7 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM:INFORMATION(continued)
Property Address: IV 1
/ UGC
Owner: An
Date of Inspection:
BUILDING.SEWER(locate on site.plan),_4W
Depth below grade:
Materials of construction:_cast iron .40 PVC . other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:J41ocate on site plan)
Depth below grade:
Material of construction: oncrete_metal_fiberglass Polyethylene
other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: l o�61x b
Sludge depth:
Distance from top of sludge to bottom of outlet tee.or baffle: ' 3y
Scum thickness: / "' a
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum.to.bottom of outlet tee or baffle: /Z
How were dimensions determined:
Comments(on pumping recommendsda tet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.): yf�
GREASE TRnI4J locate on site plan)
Depth below grade:
Material of construction: concrete_metal_fiberglass_polyethylene_other
(explain): ^
Dimensions:
Scum.thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffler
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,liquid,levels
as related to.outlet invert,evidence of leakage,etc.):
7
Page 8'of 11
OFFICIAL INSPECTION FORM-,NO'T.FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE'DISPOSAL SYSTEM INSPECTION FORM
PART,C, .
SYSTEM INFORMATION(continued)
Property Address:
Owner: -JC— J
Date of Inspection: ��/���1 7
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene 'other(explain):
Dimensions:'
Capacity: gallons .
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,'etc):
DISTRIBUTION BOX:Zif present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of
akage into or out of box,ete. :
PUMP CHAMBER: -(locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes orno):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART C
SYSTEM.INFORMATION(continued)
Property Address:
Ownerd&�
-
Date of Inspection: zc Di, )/
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain,why:
Type F _.
leaching pits,number:_
leaching chambers,number:
t�Ieachu�g 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,
CESSPOOLS,_,A(ffeesspool must be pumped,as part of inspection)(locate on site plan)
Number and configuration: '
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,:signs of hydraulic failure; level of ponding,condition of vegetation,etc.):
PRIVY.:_2&-(locate on site plan)
Materials of construction:
Dimensions: .
Depth of solids:
Comments(note conditionof soil,signs of hydraulic failure, level of ponding,condition of.vegetation,etc.):
9
Page 10 of I I
OFFICIAL INSPECTION FORM—;NOT FOR VOLUNTARY Y ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM'INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
t '
r
� 1
0(
. � o
10
Page 1 I of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: ,. 1�111.41 `�
Owner:
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water . 2_1 feet
Please indicate(check)all methods used to determine the high ground water elevation:`
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with.local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you,established the high groundwater elevation:
I1
Permit.Number: Date:
Completed by: af�`�lvae-,;
' HIGH GROUND-WATER LEVEL COMPUTATION
Site.Location: C-OcIl� Lot No.
B
,L_IJt
Owner: A/C./LCY/l"/� 'Address:
r Contractor: %>D/`�`4.0// Address: act ,�r1 I��SJ"/S/ /
a� Notes:
STEP 1 Measure depth to water table
to nearest 1/10 ft ..................... . ....... Date.
......... ......
month/day/year
STEP 2 Using Water-Level Range Zone
and Index Weill Map locate
site and determine:
OAppropriate index well.............................................:......:
OB Water-level range zone..................... G
STEP'3 Using monthly report "Current•
Water.Resources Conditions"
determine current depth to �ry/�/ Z6
water level for index well .........................:. '7 '
month/year.
STEP 4 Using Table of Water-level Adjustments
for index well (STEP 2A), current depth
to water level for index well (STEP 3),
and water-level zone (STEP 2B) 7/2
determine,waterdevel adjustment
......................:....:............:......:....:......................:.....:......:.
71
STEP 5 Estimate depth to high water
by subtracting the water
level adjustment (STEP 4)from measured depth.to water
level at site'(STEP 1) .... :_...:........ . .............................:.. ......... :.................
Figure 11--Reproducible computation form.
15
. i � y
LR
a.
Commonwealth of Massachusetts
a
Executive Office of Environmental Affalfs
Depcoroment of
William F.Weld
Oowmor
Tru:1!y d cOXe
8ea, y EOEA
David B. Simile
Commis6loner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 35 County Club D r i v e, •C MTTYf Address of Owner:
Date of Inspection: 7/17/96 (if different)
Name of Inspector: Timothy Cash
Company Name, Address and Telephone Number:
Cash' s Trucking Inc- , PO Box 7 , Yarmouthport 362-3221
CERTIFICATION STATEMENT
I celti(y that I have"personally inspected tile sewage disposal system at this address and that the information reported below is true, accurate
and complete as-of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-sire sewage disposal systems. The system:
{
X Passes
~_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails
/ Dates July 22 , 1996
Inspector's Signature: /—7 —�
ing
The System Inspector shall submit a copy of this inspection report to the to b00pgrd orrggreater,tority h evithillinspectortand0)days the systefn omne t$hall►submil
inspeclion. If the system is a shared system or has a design P
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the syslem owner and uopies'senl to the buyer, if applicable and the approving authority.
i
INSPECTION SUMMARY:
Check A, B,,,C, or D:
At SYSTEM PASSES;
I have not found any Information which Indicates that the system violates any of the failure criteria as defined In 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
e) SYSTEM CONDITIONALLY-PASSES:
One or more system components need to be replaced or tepaired. The system, upon completion of the replacement or repair,
passes Inspection.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination In all Instances. If"not determined", explain why not)
_ The septic lank is metal, cracked, structurally unsound, shows substantial infiltration or exfillralion, or tank failure is
Imminent. The system will pass Inspection if the existing septic lank is replaced will, a conforming septic lank as
approved by the Board of Health.
(revised 8/15/95) 1 '
One Winter Street • }Boston,Massachusetts 02108. a FAX(617)556-1049 a Telephone(617)282-5500
. t .
`)Printed on ltecycbd Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A . .
CERtIFICATION (continued)
Property Address-35 Country Club Drive,. Cumm.
Owner: Vilmore MacAbee
Date of Inspection: 7/17/9 6
B) SYSTEM CONDITIONALLY PASSES (continued) ,
static waterl-oberved in the
trbution bx is due trokn or obstructed
Sewage backup or breakout or high �'stributi nsbox. The syssttemrwill passinspect on ilf(with approval of the
pipes) or due to a broken, settled or uneven
Board of Health):
broken pipe(s) are replaced ,
obstruction Is removed
distribution box Is levelled or replaced y
_ than four times a year due to broken or obstructed pipe(s). The system will pass
The system required pumping more
Inspection if(with approval of the Board of Health):
broken pipes) are replaced
obstruction is removed
Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF I-IEALTII:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF IIEALTII DETERMINES THAT 711E SYSTEM IS NOT FUNCTIONING IN A MANNER
WIi1CI1 WILL PROTECT THE PUBLIC HEALTII AND SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feel of a bordering vegetated welland or a salt marsh.
1) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLICF BL SUPPLIER,
�ALTIIANp SAFETY YRAND D EERS11NE5 TttAt
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT
ENVIRONMENT:
_ The syslem has a septic tank and soil absorption system and is within 100 feel to a surface water supply of tributary to a
surface water supply.
_ •lhe system has a septic tank and soil absorption system and is within a Zone I of a public water Supply well.
_ The system has a septic lank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feel or more from a private watr
supply well, unless a well water analysis for colifurm bacteria and volatile organic compounds Indicates that the well is
free from pollution from that facility and the presence of ammonla nitrogen and nitrate nitrogen Is equal to or less than .
pl,m•
1)) SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined In 310 CMR 15.303. The basis
for this determination Is identified below, The Board of Health should be contacted to determine what will be necessary to corre(
the failure.
_ Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or,
cesspool. ,
(revised 6/15/95)
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 3 5 County Club Drive, C u mm.
Owner: Filmore MacAbee r
Date of Inspection: 7/17/9 6
Di SYSTEM FAILS (continued):
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s)..
Number of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zoned of.a public well
a
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E]LARGE SYSTEM FAILS:
The following criteria apply to large'systems in addition to the criteria above:
The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant-threat to public health and safety
and the environment because one or more of the following conditions exist:-.
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet,of f 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)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 8/15/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM (NSPEC170N FORM
PART B
CHECKLIST
k
Property Address: 35 Country Club Drive, Cumm.>
Owner: Filmore MacAbee
Date of Inspection: 7/17/9 6
Check if the following have been done:
CI g
X Pumping information was requested of the owner, occupant, and Board of Health.
X None of the systein components have been pumped for at least two weeks and the system has been receiving normal flow rates
_during that period. Large volumes of water have not been introduced into the system,recently or aS pan of this inspection.
X As built plans have been obtained and examined. Note If they are not available wilh-N/A.
The facility or dwelling was inspected for signs pf sewage back-up.
X The system does not receive non-sanitary or industrial waste flow
X The site was inspected for signs of breakout.
X All system components, excluding the Soil Absorption System,`have been located on the site.
X The septic tank manholes were uncovered, opened, and the Interior of the septic tank was inspected for condition of baffles or
tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
X The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
X The facility owner (and occupants, If different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
r f
r
(revised 8/15/95) 4 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 35 Country Club Drive, Cumm
Owner: Filmore MacAbee
Date of Inspection: 7/17/9 6
FLOW CONDITIONS
RESIDENTIAL: ,
Design flow: 330 gallons
Number of bedrooms: 3 "
Number of current residents: 2
Garbage grinder (yes or no)::N
Laundry connected to systern (yes or no): Y
Seasonal use(yes or no):N
Water meter readings, if available: 1994-95
Last date of occupancy: _
k .
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: aallons/day
Grease trap present: (yes or no)_
Industrial Waste Ilolding Tank present: (yes or n. o)— -
Non-sanitary waste discharged to the Title 5 system: (yes or no)_ }
Water meter readings, If available: .
Last date of occupancy:
OTHER: (Describe) ,
Last dale of occupancy: t
GENERAL INFORMATION „
PUMPING RECORDS and source of informations "
No pumping recorc3G i n town traaf mon+ ril )3 I`�9� `
r
System pumped as part of inspection: (yes or no)_
If yes, volume pumped: gallon
Reason for pumping:
TYPE OF SYSTEM "
X. Septic lank/distribution box/soil absorption system
Single cesspool
Overflow cesspool „
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Other(explain)
APPROXIMATE AGE of all components, date Installed (if known).and source of Information: 2_ yrs• {"
Sewage odors detected when arriving at the site: (yes or no) NL
(revised 8/15/95) 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C-
SYSTEM INFORMATION (continued)
Property Address: 35 Country Cihub Drive, Cumm.
Owner: Filmore MacAbee
Date of Inspection: &/17/9 6
s
SEPTIC TANK:_
(locate on site plan)
Depth below grade: ) "
Material of construction: X concrete _metal _FRP._ other(explain) A
Dimensions: x 8 x 5 4"
Sludge depth: 4"
Distance from (of) of sludge to bottom of outlet lee or baffle: 5 ' 4"_ A
Scum thickness: 1 t
Distance from top of scum to top of outlet lee or baffle: 1 11
Distance from bottom of scum to bottom of outlet tee or baffle: g 1 6 it
Comments:
(recommendation for pumping, condition of Inlet and outlet tees or baffles, depth of liquid level'in relation to outlet Invert, structural
integrity, evidence of leakage, etc.) Tank
Lai—
. No si n of
GREASE TRAP:_
(locate on site plan)
Depth below grade:
Material of construction: _concrete `metal _FRP_other(explain)
Dimensions:
Scum thickness:
Distance from lop of scum to lop of outlet lee or baffle;
Distance from bottom of Kom 1n bottom of outlet tee or baffle:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
Integrity, evidence of leakage, etc.)
(revised 9/15/95) 6
(
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM_
FART C
SYSTEM INFORMATION (continued)
Property Address: 35 Country Club Drive, Cumm
Owner: Filmore MacAbee
Date of Inspection: 7/17/9 6
iIGI-IT OR HOLDING TANK:
(locate on site plan)
Depth below grade:
Material of construction: _concrete `metal _FRP_other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level:
-
Comments:
(condition of inlet lee, condition of alarm and float switches, etc:)
DISTRIBUTION BOX:_ .;
(locale on site plan)
Depth of liquid level above outlet invert:---ALA
Comments:
(note if level and distribution is vqua!, evidence of+solids carnv„-ri,'evi(lence of.leakage Into or out of box, etc.)
PUMP CHAMBER:_
(locate on site plan) ,
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber,'condition of pumps and appurtenances, etc.) '
(revised 9/15/95) 7 ` �.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 35 Country Club Drive, Cumm.
Owner: Filmore MacAbee
Date of Inspection: 7/17/96
SOIL ABSORPTION SYSTEM (SAS):
(locale on site plan, if possible; excavation not required, but may be approximated by non-Intrusive methods)
If not determined to be present, explain:
Type.
leaching pits, number:1
leaching chambers, number:____
leaching galleries, number:
leaching trenches, number,length: o�a 1 .
leaching fields, number, dimensions: 9
overflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
N
CESSPOOLS: T
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert: _
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction: '
Indication of groundwater:
inflow (cesspool must be pumped as part of Inspection) .
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:_
(locate on site plan)
Materials of construction:
• Dimensions:
Depth of solids:
Comments: (note condition of soil, signs,of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 6/15/95) B
t
• f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address; 35 Country Club Drive, Cumm.
Filmore MacAbee
Owner:
Date of Inspection: 7/17/9 6
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
�r
V
DEPTH TO GROUNDWATER
Depth to groundwater: 17 .4Fe( w
method of determination or approximation:
i
trevieed 6/15/95) 9
TOWN OF BARNSTABLE $,
LQCATION 35 COUNTRY. CLUB DR.. SEWAGE #<� ssa
VILLAGE CUMMAQUID,MA. ASSESSOR'S MAP & LOT3�5, .DYJ-
INSTALLER'S NAME&PHONENO.CASH , S TRUCKING inc. 508-362-3221
SEPTIC TANK CAPACITY 11500 GAL SEPTIC TANK
LEACHING FACILITY: (type)(4) C U L T E R E C H A R G E R size)
OF STONE PACK
NO.OF BEDROOMS
3
BUILDER OR OWNER DIANE McFARLIN 35 COUNTRY CLUB dr.
10/7/98
PERMTTDATE: ___ _ COMPLIANCE DATE: JD- 9-qz?
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) i Feet
Furnished by CASH , S TRUCKING inc.
9�
o � _ _
�..c � ;:
��
_ � �
-80 07 bi—
No. Fee S Q o'
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS'
2pplication for Migool bpgtem Construction Permit
Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at:
Location Address or Lot No. 35 COUNTRY CLUB DR. Owner's Name,Address and Tel.No.
. DIANE McFARLIN
Assessor's Map/Parcel CUMMAQU I D,MA 02637
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
CASH'S TRUCKING ,ENSIGN CASH
P.O.BOX 7,YARMOUTH PORT,MA 02675
Type of Building:
Dwelling No.of Bedrooms 3 Garbage Grinder(no
Other TI pe of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil ,f t c-1 a y - t'
Nature of Repairs or Alterations(Answer when applicable) I N S T-ALAT I ONI)f ( 4 )C-U L T-E G.
RECHARGERS ( 330 )s AND 3 ft. stone pack
Remnval of all clay rgpiacging with g_P_}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 Certifi-
cate of Compliance has been issued by this Board of He
Signed 00 Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. Date Issued
---------------------------------------
Fee S G'
No
< THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
ZlIppYicatian for Dioogal 6 otetn Construction Permit ,
Application is hereby made for a Permit to Construct,( )or Repair( )an On-site Sewage Disposal System at:
Location Address or Lot No. 35 COUNTRY :CLUB tDR. Owiier's Name,Address and Tel.No.
DIANE McFARLIN
-� Assessor's Map/Parcel tQUID
e .� 02.637
Installer's Name,Address,and Tel.No. p Designer's Name;Address and Tel.No.
CASH°S TRUCKING ,.ENSIGN =CASH '
P.O.BOX 7,YARMOUTH PORT;',$4A 0-2 6 7 5
Type of Building: r
Dwelling No.of Bedroo`iais-w3 ; Garbage Grinder(nd
Other �'�'ype of BuildtR► No.of Persons Showers( ) Cafeteria(...)
` ' Other Fixtures -
Design Flow' w gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
r � ,
Description of Soil r f t. clay
- z j
i
i
Nature of Repairs or Alterations(AnswerIwhen applicable) TNSTAT ATTOW A rTr mac
RECHARGERSk (3301_s AND 3 ft.-: stone pack -
Removal of all clay anrl -rt-nlanpinTWit-h Sanfi
' * Date last inspected: x
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 Certifi
cate of Compliance has been issued by this Board of Health
Signed j Date
Application QQ t!
Application Approved by > at
Application Disapproved for the following reasons-
-- - -�'
Permit No. � Md�— "� - Date Issued"t , p
----- - ----------------- ----- ---
} . THE COMMONWEALTH OF MASSACHUSETTS
t BARNSTABLE, MASSACHUSETTS
r
(Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced( )on'
by Installer
r ' at has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. �i _ dated
Date {Q c� ` �� _ Inspector
}
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYS-
TEM WILL FUNCTION SATISFACTORY
a _—
— ———————- ------------------_Fee
No �t ..'r.—
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS t
3Diopo!6al*p76tejn on5tru tion Permit
Permission is hereby gr -ed to I ✓
to construct( )repair O an T
site e y tem located No:#
YAI
Street
and/as described in the above Application for Disposal System Construction Permit. v
- _ No. Dare .
The applicant recognizes his/her duty to comply with Title 5 and the followin)a rovisions or special -anditions.
dd
All cons c 'o st beXaompleted within three years of the date below.
Date: Approved by
Board of Health v
O10/9/97
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only:
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
I, ENSIGN CASH hereby certify that the application for disposal works
construction permit signed by me dated SEP 8 , 1 9 9 8 , concerning the
property located at 35 Country Culb Dr. ,Cummi!auid,MA meets all of the
following criteria:
• There are no wetlands located within 100 feet of the proposed leaching facility
• There are no private wells within 150 feet of the proposed septic system
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
• If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the
proposed leaching facility will Rot be located less than fourteen(14) feet above the maximum adjusted
groundwater table elevation.
Please complete the following:
A)Top of Ground Elevation(according to the Engineering Division G.I.S. map)
B)Observed Groundwater Table Elevation(according to Health Division well map)
SIGNED: DATE: �p71 X 98� I
i
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
q:health folder:cert
P /
r - -
L
�G
' I
TOWN OF BARNSTABL QQ
LOCATION 35 COUNTRY CLUB DR. SEWAGE #
VILLAGE CUMMAQU I D, MA. ASSESSOR'S MAP & LOT,a c- 0 15'
INSTALLER'S NAME&PHONENO.CASH , S TRUCKING inc . 508-362-3221
1 , 500 GAL SEPTIC TANK
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type)4) CULTE RECHARGERqsize)
OF STONE PACK
NO.OF BEDROOMS 3
BUILDER OR OWNER DIANE McFARLIN 35 COUNTRY CLUB dr..
PERMTTDATE:
10/7/9 8 COMPLIANCE DATE: 10- -q
Separation Distance Between the:
Feet
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility
Private Water Supply Well and Leaching Facility (If any wells exist Feet
on site or within 200 feet of leaching facility)
Edge of Wetland and Leaching Facility(If any wetlands exist Feet
within 300 feet of leaching facility)
Furnished by CASH , S TRUCKING inc.
G.
100,
^ Lod" �Z �
Z� � .
� EY/�+vG DtvE�uNG lit
V
#fe
I certify that this property; is
located in Flood Hazard Zone C (out-
side. the 500 year flood) as identified
by the Department of Housing and Urban
Development (HUD) .
Date._S&y'- 2 CERTI A ED PLOT PLAN
LOCATION 44
f - SCALE , .���-30 ..•. DATE Z3 /l,96
Reg. Land Surveyor PLAN REFERENCE
its, s.�owiv pns �-Y.1S,r...z2� • .
I certify to its title insurance company
that there are no Visible encroachments ICERTIFY THAT THE 4W!3>70Y�.,jN�/4a'�L/NG
or easements except as , shown' and that this SHOWN ON THIS PLAN IS LOCATED ON THE GROUND '
plan was prepared under my immediate ,
AS SHOWN HEREON AND THAT IT CONFORMS TO THE
SETBACK REOUIREMENTS OF THE TOWN OF
supervision -57r�Q�l,.� WHEN CONSTRUCTED.
DATE
REGISTERED LAND SURV R