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Home My WebLink About0084 GOVERNOR'S WAY - Health 8 c o VERNOR'S WAY, BARNSTABLE A= 258 055 -y- t p U w ti Commonwealth of Massachusetts M Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 84 Governors Way - Property Address Ariane M, St.Claire Owner Owner's Name �y information is Barnstable Ma 02360 2/3/16 required for every page. City/Town State Zip Code Date of Inspection tr Inspection results must be submitted on this form. Inspection forms may not be altered in any N way. Please see completeness checklist at the end of the form. Important:When A. General Information q3D filling out forms on the computer, use only the tab 1'. Inspector: key to move your cursor-do not Michael DiBuono use the return Name of Inspector key. DiBuono Sewer and Drain Company Name VQ 8 Johns path Company Address S Yarmouth Ma 02664 Citylrown State Zip Code 508-364-9587 S103522 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 yhe L cal Approving Authority 2/4/16 nspector'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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 i Commonwealth of Massachusetts 4 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 84 Governors Way Property Address Ariane M, St.Claire Owner Owner's Name information is required for every Barnstable Ma 02360 2/3/16 " 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: Cesspool was replaced with 1,000 Gallon septic tank at some point. The tank is H10 and pertrudes under the driveway by a foot. Home owner has a railtie in place to prevent parking on the edge of tank. First leach pit is no longer leaching. Second pit level at time of inspection was 32"from invert pipe B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not- determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 84 Governors Way Property Address Ariane M„ St.Claire Owner Owner's Name information is Barnstable Ma 02360 2/3/16 required for every - page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ElY ❑ N El ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 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 84 Governors Way Property Address Ariane M, St.Claire Owner Owner's Name information is Barnstable Ma 02360 2/3/16 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) . 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water, supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance- **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® 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 '/z day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 84 Governors Way ` Property Address Ariane M, St.Claire Owner Owner's Name , information is required for every Barnstable Ma 02360 2/3/16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No El ® 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. El ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails.-The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with-a . design flow of 10,000 gpd to 15,000,gpd. For large systems, you must indicate either"yes" or'.'no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone Il 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. l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official- Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 84 Governors Way Property Address Ariane M, St.Claire Owner Owner's Name information is required for every Barnstable Ma 02360 2/3/16 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 f ❑ ® 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 El ® 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? j ® ❑ Were all system components, excluding the SAS, located on site? i ® ❑ 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 l5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 84 Governors Way Property Address Ariane M, St.Claire Owner Owner's Name information is required for every Barnstable Ma 02360 2/3/16 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Cesspool was replaced with 1,000 Gallon septic tank at some point. The tank is H10 and pertrudes under the driveway by a foot. Home owner has a railtie-in place to prevent parking on the edge of tank. First leach pit is no longer leaching. Second pit level at time of inspection was 32"from invert pipe. Number of current residents: 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? • . El Yes ❑ No Water meter readings, if available last 2 ears usa a 189 GPD 9 ( Y 9 (gPd))� Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date, Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design4low(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? El Yes ED N Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 ' A Commonwealth of Massachusetts. W Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 84 Governors Way M Property Address Ariane M, St.Claire Owner Owner's Name information is Barnstablev' Mate d2 Code Da60 te o61ns Inspection required for every page. Cityrrown P p D. System Information (cont.) Last date of occupancy/use: bate Other(describe below): General Information Pumping Records: ' Source of information: None provided Was system pumped as part of the inspection?> ❑ Yes 0 No If yes., volume pumped: gaiions How was quantity pumped determined? Reason for pumping: Type of System: Z Septic tank, distribution box, soil absorption system ❑ Single cesspool El 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)yand a copy of latest inspection of the I/A system by system operator under contract a Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Af 84 Governors Way - Property Address Ariane M, St.Claire Owner Owner's Name information is required for every Barnstable Ma 02360 2/3/16 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: Pits are over 15 Years old Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on'site plan): 5 Depth below grade: feet Material of construction: ® cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): • 4 Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene [],other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1,000 gl Sludge depth: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments G M , 84 Governors Way Property Address , Ariane M, St.Claire Owner Owner's Name information is Barnstable Ma 02360 2016 required for every 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 24" 311 Scum thickness Distance from top of scum to top of outlet tee or baffle 42" Distance from bottom of scum to bottom of outlet tee or baffle 1" Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): No evidence of Ieaking,Tees and or baffles in place at time of inspection. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass El polyethylene ❑ other(explain): Dimensions: ` Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 84 Governors Way Property Address Ariane M, St.Claire Owner Owner's Name information required for every Barnstable Ma 02360 2/3/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tees are in place and levels are normal. 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): p Dimensions: ' Capacity: gallons Design Flow- gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 84 Governors Way Property Address Ariane M, St.Claire Owner Owner's Name information is required for every Barnstable Ma 02360 2/3/16 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 Na � Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): ; Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts . .Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 84 Governors Way Property Address Ariane M, St.Claire Owner Owner's Name information is Ma . 02360 2/3/16 required for every Barnstable page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ . • leaching fields' number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition_ of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No ponding or break out. System is still leaching in second pit. 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 ,M 84 Governors Way Property Address Ariane M, St.Claire Owner Owner's Name information is Barnstable Ma 02360 2/3/16 required for every 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.): No ponding no break out 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 g yP' � ''.�» � <.+� . �,v'r ,:ems-'•:. � d �'�� 4j?� •�'Cw� x,Zx x Y,+ r - �I s. �j itl\ S t� p '7i�* �+: r •,�`'�y�4J''y� "�F t 6'�4A�� ...' y,�a+ F p.«r+P3� �p "y i+r�5�r" xt w r1 rt„ (�, C# p f r F`S: 1 x� t, 'S� +� �• y'x t�.!�' �'X i. T, -iy' _"3'� 'F"�.,��,l�rt✓ ��C'u'? t �' `a i�c y .:y t'�`�� t'kt y ��". t, 1 Is' •.i^yd� r.Crf.�..-4 �`Y�.��1 v.��.�a �,� 4�� ,�: � '�*�`: 'x I- � -�Y��•� i S �.(y� tee' � ra} " " � �3�.� e '` } N� .. ...,.� .. '� .4.-+1''� � .�}4i`�'; Sw/z'r`4{/�_ ,. s�,�j��'4►�'�Y,:.,�nl ''�'y`.""�'b. `'>+�- ,._ ..., � '�!Astlaa:`' o:it ,'k ''�;. ... ' Commonwealth of Massachusetts W Title 5 Official- Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 84 Governors Way Property Address Ariane M, St.Claire Owner Owner's Name information is Barnstable Ma 02360 2/3/16 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide`a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: hand-sketch in-the area below ® drawing attached separately t5ins•3/13 r' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C x- SYSTEM INFORMATION(co rtinued) Property Address: Owner: 84 Governors Way,Bamstable,MA, Date of Inspection: Mr. &Mrs. David Mishldn r September 12,2000 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks • x locate all wells within 100' (Locate where public water supply comes into house). W .. x Z' N e.. 9y'i �x�r o- s� oat 3y . r a S7 uLlt .�. ,XC i revised 9/2/98 Page 10ofII k I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 84 Governors Way Property Address Ariane M, St.Claire Owner Owner's Name information is Barnstable Ma 02360 2/3/16 required for every page. Cityrrown 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: 10+ ft g 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: pate ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑' Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Property sits high on a hill nearest water venue is well below 20+ft Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15ins•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 ,.N 84 Governors Way Property Address Ariane M, St.Claire Owner Owner's Name information is Barnstable Ma 02360 2/3/16 required for every Zip Code Date of Inspection page. CitylTown State 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17' �t'�;}'r`m'�"�,.::t9 �„`'�'�,`ff.'aJq w `,�•"� :�s' �+ >i& Q3 ,��_i now i ,:� g�r.�` "% -, p �w IR `" r` $ ry k� d {1• I is. _ t - q OSA3' °S'la;j¢, S .r..•: �i � 5g , s a y J. N 1 .5 Aw I yv,_ uz :, �x h>v'� . �' ti ^J a'a-.P�,"v.; e y , 142 , } Y . - 1 sz�„� " ; `�.�"i��,'�°}t�.st�'9.,> x"` •§L",s^,Z q t ° �s'4 a'te - . _ 4 ha �f�S.'�y� ,��."��:2e��. 7d�4 aY f ��i `:aj�'�� J_'��^5f� •� - .. >� N> ,j --. 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O �J COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 8 y Go v e-I m e"-s (d o-y n �a✓n S �!a Ic / Name of Owner //wv�d Unel Address of Owner- AY G�v�✓N ✓s !nl wy. Date of Inspection: 9/l 0 b .L 02.6 3 0 �A✓✓1 / G i4 �", Name of hvgwctw:(Please Print) Troy Wiliams 3 a 1 am a DEP approved system inspector pursuant to Section 15.340 of Tide 5(310 CIWR 15.000) Company Name: Troy 1Mlllamn sontic Inapectiona MaWM Address: 19 Hummel Drive. So. Dennis MA 02660 Telephone Number: (508) 385-1300 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _v/ Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails 1 Inspectors Signanee: Date: !�/2/o� The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable, and the approving authority. NOTES AND COMMENTS Although system meets the minimum requirements set forth by the Massachusetts Department of Environmental Protection,certification is not to be construed as a guarantee of future working condition of system,piping or components. This inspection represents the conditions of the system on the Date of Inspection noted above. revised 9/2/98 Pave I aril I> SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(contirmed) Prey Address: 84 Governors Way,Barnstable,MA Owner: Mr. &Mrs. David Mishkin Date of Inspection: September 12, 2000 INSPECTION SUMMARY: Check A, B, C, of D: A. SYSTEM PASSES: 1 have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: A(/fi 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. Indicate yes,no,or not determined(Y. N, or ND). Describe basis of determination in all instances. If "not determined", explain why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection.if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to 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 revised 9/2/98 Page 2ofII I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) 84 Governors Way,Barnstable,MA Property Address: Mr. &Mrs. David Mishkin Owner: Date of Inspection: September 12, 2000 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N�9 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 HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING W A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The.system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). i 3) OTHER revised. 9/2/98 page 3of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(contimsed) 84 Governors Way,Barnstable,MA Mr. &Mrs. David Mishkin Property Address` September 12, 2000 Owner: Date of Impaction: D. SYSTEM FAILS: A11A You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described 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 correct the failure. Yes No 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. 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 Zone I 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. 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:N/,,9 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: The system serves a facility with a design flow of 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: 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) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 page 4orla SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST 84 Governors Way,Barnstable,MA Property Andress' Mr. &Mrs. David Mishkin Owner: Dace of lrupection: September 12, 2000 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes, No Pumping information was provided by the owner, occupant,or Board of Health. _ None of the system components have been pumped-for-at least two weeks and-the system has been•receivMgirormal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _ As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. , _ All system components, excluding the Soil Absorption System, have been located on the site. N1q The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid,depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: _ Existing information. For example, Plan at B.O.H. _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) (15.302(3)(b)) _ The facility owner(and occupants,if different from owner) were provided with information on the p P proper maintenance of Subsurface Disposal Systems. revised 9/2/98 page sorii SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 84 Governors Way,Barnstable,MA Owner:Date of Inspection: Mr. &Mrs. David Mishkin September 12,2000 FLOW CONDITIONS RESIDENTIAL: Design flow: /0 g.p.d./bedroom. Number of bedrooms(design): $ Number of bedrooms(actual): Total DESIGN flow ASS 8 Number of current residents: .3 Garbage grinder(yes or no):-y--:3 " Laundry(separate system) (yes or no):/Vo; If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use(yes or no):A/U Water meter readings,if available(last two year's usage(gpd):91F 40 U'6 ODU a Q//,N 1 ��/PP 3'00d -S Sump Pump(yes or no): Ne Last date of occupancy: ��a; c ¢ nc- COMMERCIAL/INDUSTRIAL: N/4 Type of establishment: Design flow: apd ( Based on 15.203) Basis of design flow Grease trap present: (yes or no)_ Industrial Waste Holding Tank present:(yes or no)— Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings,if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no) ES If yes, volume pumped: SJ DO gallons 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) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other- APPROXIMWE AGE of all components, date installed Of known) and source of information: p7 �f 3 o y [t Tr'U+vf 1 I / oCr Ycl � Jc.l 10113 177 pcv Sewage odors detected when arriving at the site:(yes or no} A/d revised 9/2/98 Page6ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(coofimbed) Prop-tY Adare": 84 Governors Way,Barnstable,MA owner Mr. &Mrs.David Mishkin Dace of fnspecvon. September 12,2000 BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction: Vcast iron_II 40J PVC Moth�er((explain) ) /J rN�K .� , 1 G./'1./ ✓�- , /CIO ft. �Y4,,.r,. DJ✓S ,�o.c G G�.ti 4— 1�✓oYc vU�.4- I`y✓11 rY " Distance from private water'supp y well or suction line A//A "� " "��^-/ �w bt c•,s ��„/f #a,.�� ✓ r„��y,�„� 6z�� / Diameter y,- Go I ti Comments:(condition of joints, venting, evidencg of leakage,etc.) 4z�+. c ,..cJwS' ��.eA 16(dc.LC r,...A L ` Wu GIG�►c�( G.Y-�J✓ . r� c e�-y��'7u/h. S�.t A-�'-fat L� � S(�u � �». �<-✓V! t f I ) N � C� 4✓S✓ w�-M OT �I7 1} D( -fiJ./•-s cJn SEPTIC TANK._(/,I (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age_ 1s.age confirmed by Certificate of Compliance_(Yes/No) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structura"ntegrity, evidence of leakage,etc.) GREASE TRAP: (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass Polyethylene other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (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 9/2/98 rage 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(confirmed) Property Address: 84 Governors Way,Barnstable,MA Owner: Mr. &Mrs. David Mishkin Date of Inspection: September 12,2000 TIGHT OR HOLDING TANK://4 (Tank must be pumped prior to, or at time of,inspection) (locate on site plan) Depth below grade:_ Materiel of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensions: ----- _ CapacitY: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order:Yes_ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX:N119 (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER: /V 9 (locate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or No)- Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) e revised 9/2/98 rage 8orn SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 84 Governors Way,Barnstable,MA owner: Date of Inspection: Mr. &Mrs. David Mishkin September 12,20000 SOIL ABSORPTION SYSTEM(SAS): / (locate on site plan, if possible; excavation not required,location may be approximated by non-intrusive methods) . If not located,explain: Type' r� 1- G 'x6.' Pi W; r Sas�< . leaching pits, number: O . - /D'X leaching chambers,number:_ P t ~ 5�++.�t. leeching galleries,number:_ Ieaching trenches,number,length: leaching fields,,number, dimensions: overflow cesspool,number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) 4 .� N .n ,,...,;, w,.`1+.r I LJ�.l � L u 7` � .,.,.� ,'f 'd.z /w r 4-w...l CE .t.1 } .L t J S U S (S hc�f a ✓u.✓.:,ti�t,e 4L. CESS OOLS:?gv✓ �i 1l-✓rL WU /1. (locate on site plan) r hj c uy"I ' '3 °'� S}.Sf<�^+ or js i - .,y. Number and configuration:_ (J H i !��;,, e s t�.4,> 1 Depth-top of liquid to inlet invert:_2 Depth of solids layer:. /0' Depth of scum layer: A16N,15- Dimensions of cesspool: 6 'Cke, Materiels of construction: r____s�—s Indication of groundwater:_ /✓0An /1 inflow (cesspool must be pumped as part of inspection) C S S s�u� I w� ) ,>✓.,,,o�� ,� N r Comments: (note condition of soil, signs of hydraulic failure, level of onding, condition of vegetation, etc.) c I'mr -Irtn. �h. PRIVY: III(A (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 9/2/98 Page 9orit SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:Owner: 84 Governors Way, rn Bastable MA Date of Inspection: Mr. &Mrs. David Mishldn September 12,2000 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100• (Locate where public water supply comes into house) )21, IN, yy' sj oat /0 ,xG revised 9./2/98 Page 10of I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEJIII INFORMATION(continued} Prop"Address: 84 Governors Way,Barnstable,MA Owner: Mr. &Z Mrs. David Mishkin Date of Inspection: September 12,2000 NRCS Report name Al//a Soil Type Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater 18f Feet Please indicate all the methods used to determine High Groundwater Elevation: / Obtained from Design Plans on record y Observed Site iAbutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators,installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must bel._completed) /LL �- c: f a...J o�.. "1,r,. L. ✓u v. .A vJ 4 c/: J �.p1. ✓U t / 2 W UJ 1 H o+ L.G /0 L c.7 < A h .� N L G /�i vc�J'..! c� hJ�-)A-, A(,c/.u.'�4 ti . revised 9/2/98 Page 11 of 11 l 1li:Ui; , - LiF1'�JIL: � tll'=Ni<:.1tJ PH Li _ F'ACa� U SAVE THIS INVOICE FOR YOUR GUARANTEE V J SEE BINDING TERMS ON REVERSE ��ATtON fluff. '17S ��+�� 8ERV1C E NI tAN'8 NAME L Ia MIS ! a# v�^^V!G DATE OF SERVICMwmdxmft E } 1�N'642"MOW Ell�LJ V o V i SEWER 6 DRAIN❑ PLUMBING❑ PUMPING U'_§TOMEA NA CA S NEIGHBORHOOD PLlfM65R" _ INDUSTRIAL❑ EXCAVATION El DRAIN TILE❑ 11S �---- CU9TOMEA No. CUSTOMER CLASS V l - ' RESIDENTIAL _ COMMERCIAL 08 ADDRF„gS � �..,,,, .[. r `, 0 �� APT.NUMBER FEDFRAL I.D rr ITY V 31-110229 STATE/PR OVINCE ZIPIPOSTAL CUSTOMER TELEPHONE NUMBER P.O.NUMSER/AUTHORIZATION_� WOI ES TIE RK ORDER AUT404IZATf0NATE -- — --- - My estim"Ihb authorize Roto-Rooter to perform the described services and I agree to pay the amounts indicated`-I understand t Ro -Rooter is not respon6ible for performingroken, 6ettlgd, rusted, deteriorated, or lead pipes,fixtures, or Clean outs and any damage resulting fir eaning of repaid uch lines. (PRINT NAME) (SIGNATURE) $ COMPLETION I ack ow completion of he ow described wo which has been don to my co to ea efaction. (SIGNATURE) REPAIR CODE DESCRIPTION OF WORK LAI30R$ - (20+(2)a PARTS$ RESIPENTIAL GUAR T OMM R 1AL UARANTEE PAYMENT LABOR IAnoMISC.SUPPLIES$ 4.95 Main/Branch Lines 1i months Main/Branch Lines Q 30 days ❑ CASH OFF HOURS CHARGE$ Toilet Auger . ❑7 da 6 Toilet Auger CHECK/CMEQUES NO./ .� Y 9 Q24 hours OTHER$ Plumbing Repair. ❑6 months•Plumbing Repair Q 90 day® CREDIT CARD TAX$ NET S DAYS INVOICE TOTAL$ _ `~- Plumbing Replacement ❑1 year Plumbing Replacement ❑90 days OVER 30 DAYS=LATE CHARGE OF 1 In%PER MONTH REASON FOR NO GUARANTEE "" *In the event check/cheques Is returned,the COMPANY will Charge the CUSTOMER A$26.00 prooeeaing tee. MEN M. PLEASE PAY FROM THIS INVOICE - PLEASE COMPLETE AND RETURN THE ATTACHED SURVEY. YOUR OPINION IS IMPORTANT TO US. oinleto T When plumbing breaks. Ask about our remember Roto•Rooter � does fast, dependable, guaranteed plumbing. exclusive line .of — For any installation, repair AIM drain care or service, give us a call. Products! �O We do plumbing. RQQ1' /f. ►��-__n_ Visit our web site at www.rotorooter.com TROY WILLIAMS r A� SEPTIC INSPECTIONS Certified by MA Department of Environmental Protection 9 (50.8)j385-1300 19 Hummel Drive °ceA 199 = South Dennis, MA 02660 �r,4 9vs e 8 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAI SI COPY DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON, MA 02108 617-292.5500 WILLIAM F.WELD Governor TRUDY CORE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A F. CERTIFICATION Property Address: 85'Go✓or.,ory Iry y f3 1 s h,.6 I-,L_ Address of Owner: M Date of Inspection: 5l15/1-3198 `� �4-b ra S k h (If different) Name of Inspector: T r oy W i l l i am s �5r Gov r S t,Juy am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000), 13,, 4L_ A4 Company Name: Troy .Williams Septic lnspectio.ns c�2� 3o Mailing Address: 19 Hummel Drive , Snuth flannis , MA 02660 Telephone Number: (5 0 8) 38 5-13 0 0 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-s7passes wage disposal systems. The system: _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: J 6:1+r Date S//3 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 god or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, 8, C, or D: A) SYSTEM PASSES: V 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. COMMENTS: 81 SYSTEM CONDITIONALLY PASSES:" l��q 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. Indicate yes, no, or not determined (Y, N,or ND). Describe basis of determination in all instances. If'not determined%explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health a. P.9, 1 of 10 P SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A "CE RTIFICATION (continued) 84 Governors Way,Barnstable, MA Property Address: David&Barbara Mishkin Owner: May 13, 1998 Date of Inspection: BJ SYSTEM CONDITIONALLY PASSES (continued)A114 Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to 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 q FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: /V1,9 Conditions exist which require further evaluation by the Board of Health in order to determine i(the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, I1 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than S ppm. Method used to determine distance (approximation not valid). 3) OTHER I� . f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 84 Governors Way,Barnstable,MA Owner: David&Barbara Mishkin Date of Inspection: May 13, 1998 D) SYSTEM FAILS: A114 You must indicate ei;,.er "Yes" of "No" as to each of the following: 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 correct the failure. Yes No 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. 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 Zone I 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 frorrl 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 (AILS: Ai1� - You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 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: 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) 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. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST 84 Governors Way,Barnstable,MA Property Address: David&Barbara Mishkin Owner: May 13, 1998 Date of Inspection: Check if the following have been done: You must 11 indicate either "Yes" or "No" as to each of the following: Yeses No - Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system 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 part of this inspection. �C _ As built plans have been obtained and examined. Note if they are not available with.N/A. _ The facility or dwelling was inspected for signs of sewage back-up. ►� . _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. A _ All system components, excluding the Soil Absorption System, have been located on the site. /IZI The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material-of construction, dimensions, depth of liquid, depth of sludge, depth of scum. / The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal System. _ Existing information. Ex. Plan at B.O.H. ✓. _ Determined in the field (if any of the failure criteria related to Part unacceptable) [15.302(3)(b)j C is at issue,+approximation of distance is (-i-d 04/25/971 "' , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 84 Governors Way,Barnstable,MA Owner: David&Barbara Mishldn Date of Inspection: May 13, 1998 RESIDENTIAL: FLOW CONDITIONS Design flow:SS G g.p.d./bedroom for S.A.S. ` Number of bedrooms: S Number of current residents: Garbage grinder (yes or no): V GS Laundry connected to system (yes or no): Y,- Seasonal use (yes or no): /V o Water meter readings, if available (last two (2) year usage (gpd): doo Sump Pump (yes or no): Na _ y 't/O^: �6 �97 //D�ouO y 4 //aH S Last date of occupancy: COMMERCIAUINDUSTRIAL N�yg Type of establishment: Design flow: aalIons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no) Non-sanitary waste discharged to the Title 5 system: (yes or no) Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection (yes or n) it/os If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM T 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)' ILA Technology etc. Copy of up to date contract?, Other APPROXIMATE AGE of all components:.date installed (if known) and source of information: t r � • � C c.s � J } Sewage odors detected when arriving at the site: (yes or no) Nv SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 84 Governors Way,Barnstable,MA Owner: David&Barbara Mishkin Date of Inspection: May 13, 1998 BUILDING SEWER: Al/9 (Locate on site plan) Depth below grade: Material of construction: _cast iron _ 40 PVC _other (explain) Distance from private water supply well or suction line Diameter " Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:,_[///9- (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: " Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: Comments: (recommendation for pumping, condition of inlet and outlet tees of baffles,,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) GREASE TRAP: (locate on site plan) 11,19 Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene —Other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum.to bottom of outlet tee or baffle: Date of last pumping: Comments: (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.) (r-i-d 04/25/97) _ ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 84 Governors Way,Barnstable,MA Property Address:Owner: David&Barbara Mishkin ` Date of Inspection:May 13, 1998 TIGHT OR HOLDING TANK (Tank must be pumped prior to, or 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 level: Alarm in working order_Yes; No Date of previous pumping: _ Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: N119 (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER:I 4 (locate on site plan) Pumps in working order: (Yes or No) M Alarms in working order (Yes or No) Comments: v (note condition of pump chamber, condition of pumps and appurtenances, etc.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 84 Governors Way,Barnstable,MA Owner: David&Barbara Mishkin Date of Inspection:May 13, 1998 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: 6',e- 6 5l% L o: 5/7, leaching pits, number: 6"-c /b 'x C 4- Soh leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) .+h✓� IrJ/ , VJ 4 i ` C-J.G- S S .J C- Lw CESSPOOLS: p✓ j ti s h (locate on site plan) Number and configuration:_6 ti k'%_1 Depth-top of liquid to inlet invert: y" Depth of solids layer: Depth of scum layer: A16 Dimensions of cesspool: 6 Materials of construction: Indication of groundwater: /V0 A-:- inflow(cesspool must be pumped as part of inspection) C�-s y �-s YOJti W 4 �'G✓ Comments: (no condition of soil, signs of hydraulic failurof ding, condition of vegetationelc.)� 7 � — � w / PRIVY: '119 (locate on site plan) Materials of construction: Depth of solids: Dimensions: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (r—i—d 04/25/97) D•o. a .,! �n SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 84 Governors Way,Barnstable,MA Owner: David&Barbara Mishkin Date of Inspection: May 13, 1998 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate here public water supply comes into house) b �y yy f N (r.vt..a 04/25/97) P.O. 9 of 10 ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 84 Governors Way,Barnstable,MA Owner: David&Barbara Mishkin Date of-Inspection: May 13, 1998 " Depth to Groundwater_ Feet — adjusted high groundwatcr level Please indicate all the methods used to determine High Groundwater Elevation: /Obtained from Design Plans on record t/ Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. Must be completed) L! Gt / d�✓o �, c�r w t t� b C.l l^� v� ,w. .,, Ir•v1••d 04/25/971 ` P•a• LO C T IOM' S E A�E PRNIIT N0. VILLA INSTA LLE 'S N ME & ADDRESS �D OR 7NER k�N SA t,OA HIV DATE F E R M I T IS ED DATE COMPLIANCE ISSUEDle ..�1 —'`j� I i Tow 4 �-ja� C!� No.......`f r�.. .... Fas. ... THE COMMONWEALTH OF MASSACHUSETTS \� BOARD OF .HEALTH \ Applira#ion -fur Miivuuttl Works Tomitrurtion Wruid Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal yj= at: - 1 ----------------------• . -: Lo ion.Address or Lot No. ... .. . •.. --------- ---------------- . .............. W • ss ------••-•-------•----------------------- .... • � Installer / Address UType of Building Size Lot_j__!dt#4JG_-._Sq. feet DwellingkNo. of Bedrooms_3------------------------------------- Attic ( ) Garbage Grinder ( ) a-1 Other—Type.of Building ____________________________ No. of persotis..a-------------------"Showers ( ) — Cafeteria ( ) dOther fixtures ----------------•--•-------------------------------------------------------------------------------------------•------------------------------------ W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity------------gallons Length................ Width................ Diameter______.-__- _.-- Depth-__...____--- x Disposal Trench—No..................... Width. .-. _._....._.... Total Length---------------i... Total leaching area..-.--.-_--.___----sq. ft. Seepage Pit No----- Q-_______-_-_ Diameter...... . .---. Depth below inlet---� ......... Total leaching area------------------sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date---------------------------------------- Test Pit No. 1................minutes per inch Depth of "Pest Pit-.----__--__---__-_- Depth to ground water--------.---.----_.----- f1 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water.............------_-__. -------------- ---------------------•--------------------•-----------------•-----------•--------------------------------------- O Description of Soil.......... .. w --------------------------------------------5-1,-A.0 ------ -C-1/ e Va � �--- L�--------- x -------------- ------------------------------------------------------------------------------------- ------------------------------------ U Nature of P.V < ' s or Alterations—Answer when applicable.._.... ..-----I.___�(r.-.-- _./a�� ------------------' ................... . GJ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article \I of the State,Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance hasAbee*iued b the oar health. Signed- ----------- �. Date ApplicationApproved BY �� a...- --- --- ------------------------------------------------------------------------- ---------- -s-7�-- Date Application Disapproved for the following reasons--------------•--......'........--•-------------.....----•--------------•--.......---------------•--.....--------- -•--------------------------•-----............_........------....._.......•--------------.----------•--•-----........---•----------------------------------......----------------..........-------- Date Permit No. } g Issued---•--/Q --------_------ Date -— No.......V 7 ............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...... ........... ... __........OF............................................................................... Appliration -for Ui!ivviial Works Tomitrurtion Vrrutft .'Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: ar Ate. ................2A....'2VA 4 .............--------- ........ ................................................. ----------- o �o ,iorf-Address iW or Lot No. LOC'1`0 _- --- ----------- ......:---_--------------------------------Z_ ss ------------------------------------------------------ ----------- .......................................... ....... A WA. Installer Address U Type of Building Size Lod� _'----Sq. feet" Dwelling 4e*-No. of.,Bedrooms.._. ....... . ............ .............Expansion Attic Garbage Grinder Other—Type of Building ------------------------- No. of persons.- ------------------- Showers Cafeteria Otherfixtures -------------------------------------------_----_-------------------------------------------I---------------------------------------------------- 1),esign Flow--------------------------------------------gallons per person penday. Total daily flow......................................._flow............................._......... ---gallons. C4 tic"T'ink—Liquid capacity..... ..._gallons Length------- Width-----__....... Diameter....._ ------ Depth.. ..._. .. .-Disposal Trench—No- -------------------- Width&......... -------------Total Length---------------i... Total leaching area....................sq. ft. '.,Seepage Pit 'No......3------------ Diameter .. ..... Depth below inlet area.ia ter------- I ........ Total leaching area......_....._---sq. ft. Other Distribution box Dosing tank Percolation Test Results Performed by.......................................................................... Date------------------------------------- Test Pit No. I................minutes per inch Depth of Test Pit------------_------ Depth to ground water___._._.._..._....___. f1 Test Pit No. 2................minutes per inch Depth of Test Pit.........._--_-_---. Depth to ground water..........._........._: - --------------------------------------------------------------- --------------------------- --------------------- ----------------------------------------- ---------- " 0 Description of Soil----------- - ....... -_e-------------------- A_ 4.1-00 4----------------------------------- U --------------------------------------------5 stall---- & ------------ ----_-----------------/-& ----I&I-A.A41------- A0 U Nature of R(i -3- or Alterations—Answer when applicable..------�Uzdi -------- ..... ...... _�_.atmemvw---------------------- ------------ --- ------------- ------------- e : �W Agreement: e- The undersigned agrees to install' the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—.The undersigned.further agrees not to place the system in operation until a Certificate of Compliance has been issue th" kt.d -----_---------------------- 4---------------------------- eA Date Application Approvedjqy_,_r,,_� - ----------------- ......... Application Disapproved for the following reasons:. . . EO., 11. ......... .t'! ............------------ ................. ................................................................................................... --------------- ------------------------------------------------------------------------------------ Date PermitNo. ..................................... Issued....... ... --A------ . .............. Date '.THE.,,-COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............ .......:..OF .................................... tr of 10.11amVIt'aurr THIS I, ,Q CERTIFY, That the Individual Sewage Disposal.System constructed or Repaired r .......I..................................................................................................... by------------------------------------------------ nw�4............... / OeX A-OAJ V.4 at Installer........&---------------------------------------------------- --------------:--------------------------............................................. has heeri installed in accordance with the provisions"qf Article XI of The State Sanitary Code as described in the application for Disposal Works,'06"ns'truction Permit NN' ------ dated.------- THE ISSUANCE OF THIS (CERTIFICATE I.SHALL NOT BE E.CONSTRUED AS A-GUARANTEE THAT THE SYSTEM' WILL-FUNqTION SATISFACTORY.'.- D A T E Inspector.-.--- ........ --------------------- -------%-------------------------- -'s THE COMMONWEALTH OF .MASSACHUSETTS BOARD 017 H- LTH ...OF....................... ..,.............. ............................... No._ 3:13.... FEE... .............. Permission is hereby granted............. e&-.t ........................ ------- -------------------------------------- to Construct or Repair an Individual Sewage Disposal System ---- --------- .... ------------------------------��_: . ...... at No............ .........fik. -Y------------- l Street A: -- "31 as shown on the application for Dsposal,Works Con mitD.Ff.tijit No Dated._.... :a A ............................................ -------- .......................... Boa o Health W DATE-.--. A0 4`1 ------------ FORM 1255 H086S & WARREN. INC_ PUBLISHERS k _fi Z rsfi Fko L, vi tiy � . F l3e d r 0a l� C5�° .- Lase weAf— 1Zo v r� l�aa