HomeMy WebLinkAbout1492 HYANNIS-BARNSTABLE ROAD - Health 1 02 Hyannis-Barnstable Road
Barnstable
A= 298 —023 —001
,
Commonwealth of Massachusetts
W Title 5 Official- Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .
1492 Hyannis Barnstable Road
Property Address
Edward Razzik s '
Owner Owner's Name "
information is Barnstable '. " ' MA 02625 5/11/11req
uired wired for every ry
page. City/Town. w State Zip Code Date of Inspection'
Inspection results must'be submitted on this form. Inspection forms may not-be altered'in any
way. Please see completeness checklist at the end of the form.
Important:When n
filling out forms A. General Information-' - - ;
on the computer, • .- \e�
r \J1
use only the tab 1. Inspector: • - �
key to move your
cursor-do not
use the return Ricky L. Wright
key.
Name of Inspector, -
B & B Excavation, Inc: -
rab Company Name
14 Teaberry Lane _
. Company Address
rerun — s
:Sandwich MA .02563
Cityrrown State Zip Code'
508-477-0653 ry S 14595
Telephone Number License Number
B. Certification '
I certify that I have personally inspected'the sewage disposal system at this address and that--the a
information reported below is true, accurate and complete as of the time of the inspection. T.he inspection
was performed based on my training and experience in the proper function and'maintenance�of onsite•
sewage disposal systems.-I am a DEP approved system inspector pursuant to Section'1,5.340 of
Title 5 (310 CMR 15.000).The system: t
® Passes ❑ Conditionally Passes,' ''
❑ Falls a�
❑ Needs Further Evaluation by the Local Approving'Authority
r7?
a
' 5/11/11 „
Inspector's-Signature ,` Date ,
The system,inspector shall submit a copy of this inspection report to the Approving Authority (Board
• of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the,
report to the appropriate regional office of the DEP,The original should,be sent to the system owner'%'
' and copies sent to the buyer,•if applicable„and,the approving.authority.
****This report'only describes-conditions at the,time of inspection and under the.conditions-of use.
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal Sy m age 1 of 17
h -
Commonwealth'of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 1492 Hyannis Barnstable Road
Property Addressf;
Edward Razzik
Owner Owner's Name
information is Barnstable. ` ` MA , 02625' 5/11/1,1`
required for every ,
page. City/Town "' State Zip Codes Date of Inspection
B. Certification (cont)
Inspection Summary: Check A,B,,C,D or.E/always complete all of Section D,
A) -System Passes: ti
' M-1 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'chteria not evaluated are "
indicated below.
Comments:
r,
. i
B) System ConditiohallyaPasses: a -
0 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"4or,`not determined" (Y, N, ND)for the following statements. If;'not
determined," please explain
The septic tank is metal and over 20 year's old* or the-septic tank(whether metal*or not) is structurally
W unsound, exhibits substantial infiltration or exfiltration or~tank failure is imminent. System will pass r
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 Y.is structurallyrsound,=not leaking and if a Certificate.of
Compliance indicating#hatthe tank is less than 20 years old is available.
s
❑ Y N ❑ ND (Explain below).
t5ins•09108 i.
Title 5 Official Inspection Form:Subsurface Sewage`Disposal System•.Page 2 of 17. .
Commonwealth of Massachusetts f
W Title 5 ®f f icial, Inspection For-
Subsurface Sewage Disposal System Form Not for Voluntary Assessments,.,
°M 1492 Hyannis Barnstable Road
Property Address _
Edward Razzik
Owner Owner's Name
information is
required for every Barnstable MA 02625 5/11/11
Pa Cityfrown State Zip Code Date of Inspection
9e. •:
B. Certification (cont.)
B) System Conditionally,Passes (don .): ,
❑ Observationof sewage backup or break out or high static Walter level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box`System will
pass inspection if(with approval of Board of Health): -
broken pipe(s)are replaced ❑ _Y ❑ N ❑ ND (Explain below):
❑.' obstruction is removed* ❑,.Y ❑ N ❑ ND (Explain below):
-❑ distribution boz is leveled or replaced ❑ Yr •`❑ ;N .❑ ND'(Explain below):
•q o'
❑ 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):
El obstruction:is removed ❑ Y ' ❑ 'N ❑ ND (Explain below): "
w
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,
Msafety 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•09/08 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
4.
^M 1492 Hyannis Barnstable Road
Property Address -
Edward Razzik
Owner Owner's Name
information is
required for every Barnstable MA 02625 5/11/11
page. CitylTown T State Zip Code Date of Inspection
B.'Certification (cont.)
2. System will fail unless the Board of Health and Public Water Supplier, if?an
Y l Pp � Y)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic,tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has aseptic tank and SAS and the SAS is within a Zone 1 of a public water
supply. ,
❑ The system has-aseptic 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,priyate water supply well". '
Method used to determine distance:
**This system asses if the well water anal sis performed at a DEP certified Y p y . ,.p rt ed laboratory, for 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:
- • . � .. ., . , � .. _ ICI
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
., —
Yes No W
z
El
Z Backup of sewage into facility or system,component due to overloaded or
y clogged SAS or cesspool
❑ ® ti Discharge or ponding,of effluent to the surface of the ground or surface waters
'due to an"overloaded or clogged SAS or cesspool
El ® Static liquid level in the distribution box above outlet invert due'to an overloaded-
or clogged SAS or cesspool
Liquid depth in cesspool is less than 6" below invert or available volume is less
❑'' ® than '/2 day flow
t5ins•09/08 k
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts'
W Title 5 Official Inspectioh Form
Subsurface Sewage Disposal System Form - Not for Voluntary.Assessments
•
1492 Hyannis Barnstable Road
4•,M .
Property Address i.
Edward Razzik•
Owner Owner's Name r
information is
required for every Barnstable MA i 02625 5/11/11
page. Cityrrown State .Zip Code.. -..Date of Inspection '
B. Certification`(cont.) a f
r Yes No
El ® Required purrriping 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 surface water supply. .
❑ ®} Any portion of a cesspool or privy is;withinya Zone 1 of a public well.
s _ b
❑ ® _- 'Any portion of a cesspool o'r.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'
}z 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
F 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- -
.` y - 4
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
a system owner should contact the Board of Health to determine what will be
necessary to correct the failure.. AI f
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"rio"to each of'the`following, in addition to the
questions in Section'D. i
Yes No F
❑ 0 . 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'riitrogen 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
p system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
L` •
Commonwealth of.Massachusetts
W Title 5 official Irspection . Form :
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 1492 Hyannis Barnstable Road,
s
Property Address
Edward Razzik '• �
Owner Owner's Name e
information is, `
required for every Barnstable " MA M625 5/11/11
page. CitylTown ,State `Zip Code Date of Inspection
C. Checklist
Check if the following have,beendone. 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
❑ ® .I 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? -
❑ ® k' 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); r
E _ !El, ; 1 Was the facility or dwelling inspected,for.signs of sewage back up?
® - ❑ - = .Was the site inspected.fb'�signs'of break out? r
W
® El . • Were all stem corn onents excluding the SAS located on i
. � F Y ,P . • 9 site?-
El® ❑ Were the septic tank manholes uncovered op
ened,,e ed .and the in •
p p tenor 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?
Ei ® '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:
❑ 0; Existing information. For example,*a.plan at the Board of Health.
El
` 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*I formation
Residential,Flow Conditions:
-4
Number"of bedrooms(design). .Number of bedrooms(actual): ` 4
DESIGN flow tiased;on 3�10 CMR 15.203 (for"example: 110 gpd�x#of bedrooms):} 440
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5.®fficial Inspection Form
Subsurface Sewage,Disposal System Form-,Not for Voluntary Assessments
^M 1492 Hyannis Barnstable Road
Property Address °
Edward'Razzik
Owner Owner's Name f
information is Barnstable MA 02625 5/11/11 .
required for every '
page. City/Town State Zip Code Date of Inspection
D. System Information
i
Description:
Number of current-residents: ' } 0
X.
a Does residence have a garbs9 grinder?, r ❑ Yes ® No,
_
1 � y
Is laundry on a separate sewage system? [if yes separate inspection required] ? ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal uses - ❑ Yes ® #No
Water meter readings, if available (last 2;years usage (gpd)):
n/a
Detail: „
Sump pump? - ❑ Yes ® -No
k 2 years ago
Last date of occupancy:
b r Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): <y-
Gallons per day(gpd)
Basis of design flow(seats/persons/soft, etc.)`. b
Grease trap present?_ `Q Yes ❑ No
Industrial waste holding tank present? r ° ❑ Yes,❑F No .
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ 'No
Water meter readings, if available: «,
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17.
I
Commonwealth of Massachusetts
W Title 5 Official 'Inspection Fora
Subsurface Sewage Disposal-System Form - Not for Voluntary,Assessments
1492 Hyannis Barnstable Road
s
Property Address ,
Edward Razzik
Owner Owner's Name
information is Barnstable ? ' A. MA : s' 02625 .r , 5/11/11«
required for every
page, City/Town
',,State Zip Code Date'of Inspection
D. System Information (cone.) ?' t
,. A-
r g
Last date of occupancy/use ' '
Date
Other(describe below) R ,
;r
General Information
Pumping Records: 3
Source of information ,
Wass stem pumped as art of the inspection? }
Y P p P p � 0 Yes ® No
If yes,-volume.pumped' k Y +
., gallons �.
How was quantity pumped determine)?.
Reason for pumping -
Type of System:
, Septic tank, distribution box, soil absorptionrsystem a
Single cesspool w ` ,
® Ove,rflow cesspool
❑ Privy. r. •: '* - ;� , . : , _ � ,. -
r:,
0 ;� Shared system (yes or no) (if yes, attach previous inspection records, if any)
ElInnovative/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
FT
Tight tank�.-zAttach a copy of the DEP approval.
1.7
® -Other(describe):
: -
(1)6x8 cesspool piped into two overflow cesspools both�6x8 i
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
. Title 5 official Inspection Form.
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
1492 Hyannis Barnstable-Road t -'
Property Address tf' ,
Edward Razzik
Owner Owner's Name
information is Barnstable MA_ 02625, , ~,, 5/11/11
required for every -
page. Cityrrown State Zip Code Date of Inspection
D. System Information (coat.) -
Approximate age of all components, date installed (if known)and source of information.
30years :, P
Were sewage odors detected when arriving at the site? ❑ `Yes ® No
Building Sewer(locate on site plan):
2,.
9
Depth below rade: " ,
P
.feet -
Material of construction:
® cast iron ❑40 PVC' '❑other(explain): 4
Distance from private water supply well or suction line: :feet
Comments(on condition of joints, venting, evidence of-leakage,'etc.):
At time of inspection building sewer appeared to be in good shape no si ns of leakage or blockage.
Septic Tank(locate on site plan):
Depth below grade:' feet
Material of construction:
❑ coricrete ❑(metal ❑ fiberglass .;❑ polyethylene ❑ other(explain)
•
If tank is metal, list age:_
years
Is age confirmed by a Certificate of Compliance? (attach a copy`of certificate) ❑: Yes ❑ .No
Dimensions: '
Sludge depth: _
Tins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
- Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1492 Hyannis Barnstable Road
Property Address ,
Edward Razzik
Owner Owner's Name
information is required for every Barnstable a MA. 02625 }5/161/11
page. City/Town State Zip Code Date of Inspection
D. System Information.(cont.)
Septic Tank(cont.) .
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to.top of outl et,tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition,.structural integrity,
liquid levels as related to outlet'invert,'evidence of leakage, etc.):
, T
_ F
Grease Trap (locafe,on site plan):
Depth below grade:
ti feet
Material of construction: 4
❑ concrete ❑ metal` µ t ❑ fiberglass ❑ 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
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts '
W Title -5 official Inspection Foam
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 1492 Hyannis Barnstable Road '
Property Address k ''
Edward Razzik
Owner Owner's Nameinformat
required lon forlevery Barnstable .-.MA ' ;'" 02625. 5/11/11
page. Cityrrown _ State Zip Code Date of Inspection
D. System Information,(cont ) i
Comments(on pumpingrecommendations;inlet and outlet tee or baffle condition, structural integrity,
I
liquid levels as related to outlet invert"evidence of leakage,etc.):
w Tight or Holding Tank(tank must be pumped'at time of inspection)-(locate-on site plan)`.
I .
Depth below grader 4
Material of construction: w
❑ concrete ❑.metal .+ ❑ fiberglass ❑Tpolyethylene Elother(explain):
. a
.A
Dimensions:
Capacity: n
. gallons •
Design Flow:
gallons per day
Alarm present. El 'Yes ❑.-No
Alarm level: : :{. Alarm in working order: ❑ Yes ❑ No.
Date of last;pumping: Date_
y z 4f k. s
Comments (condition of alarm'and float switches, etc.):
• - ,. '%� are. _ • .. '.
*Attach copy of current pumping contract(required). Is copy attached? . ❑ Yes i' ❑ No '
thins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title• 5 official Inspection Form,
_ Subsurface Sewage'Disposal System Form -,Not for Voluntary Assessments
�^M 1492 Hyannis Barnstable.Road
Property Address,- -
Edward Razzik.
Owner Owner's Name
information is. + e
required for every Barnstable - -�' MA " 02625 5/11/11
,.
page. Cityrrown `_ State Zip Code Date of Inspection.
D. System Information (cont.) a - "
Distribution Box (if present must be, pened).(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 leakage into or out of box,'etc)
Pump- Chamber
a ber(l
ocate on site plan):
Pumps in working order: . ❑ Yes - ❑ -No
•
. _
Alarms in working order . . o ❑ Yes ❑1 No
Comments (note conditiori of pump chamber, condition of pumps,and appurtenances,'etc.):
T
Soil,Absorption System:(SAS) (locate on,site plan, excavation not required):
If SAS not located, explain why;
t5ins 09/08. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
J
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form,Not for Voluntary Assessments
°M 1492 Hyannis Barnstable Road
Property Address
Edward Razzik
Owner Owner's Name
information is required for every Barnstable MA` 02625 5/11/11
page. CityfTown State Zip Code, Date of Inspection -
D. System Information-i(cont)El
,...
eachin its numbe
r:
r:
❑ leaching chambers - < number: r.
❑ leaching galleries number:
❑ leaching trenches number,Hlength =
El
leaching:fieldsk "number, dimensions: r
4
Z overflow cesspool t number: (2)6x8
❑ innovative/alternative system
Type/name of 1echnology.
Comments (note condition of soil, signs of hydraulic failure, level of poriding, damp soil, condition of
vegetation, etc.): ... .
At time of inspection leaching appeared to be ingood shape no sign of staining°or hydraulic
failure.Leaching was dry.at time of inspection."
Cesspools (cesspool must'be pumped as part of ins ection) (locate on+.site pIan :'
Number •(1) piped into two(three total)
and configuration
Depth-top of liquid to inlet invert s 3 '
Depth of solids layer4 A
Depth of scum layer, no scum
6x8.
Dimensions of cesspool
Materials of construction block
Indication of groundwater inflow ❑ -,Yes ® No
t5ins•09/08 ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts "
Title 5 Official "Inspection .Form
Subsurface Sewagi,Disposal System Form - Not for Voluntary Assessments
°M 1492 Hyannis Barnstable Road
Property Address
Edward Razzik
Owner Owner's Name
information is f
required for every Barnstable , . MA 02625 5/11/11
page. ` Cityrrown 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. .
At time of inspection cesspools appeared to be in good'shape no'si n of hydraulic failure or backup
t
L
Privylocate on site plan);
+ t
i
Materials of construction:
Dimensions _> v
Depth of solids
s.
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.): , .
rt
9
• r
k
% - ' k , •.
` t5ins-09/08 t . Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
z.
c
Commonwealth of Massachusetts
Title 5 Official Inspection Form -
o Subsurface Sewage Disposal System Form -,Not for Voluntary Assessments
wM 1492 Hyannis Barnstable Road
Property Address
Edward Razzik
Owner Owner's Name ,
information is s `
required for every Barnstable MA ; 02625 5/19l11
page. Citylrown 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 F
❑ drawing attached separately
- ♦LA
A2> zg
a.
49 S "
e .
!Sins.09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1492 Hyannis Barnstable Road
I
Property y P Y Address _
Edward Razzik
Owner Owner's Name a
information ,
at on is
required for every Barnstable MA 02625• _ 5/11/11
page, City/Town
State Zip Code Date of Inspection
"„D. System information (cont.)
[4 9t
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells >12
#`
Estimated depth to high ground water. feet
Please indicate all methods used determine the hi h round water elevation: -
- 9 9
❑. Obtained from system design plans on recordR
If checked, date,of design plan reviewed: pate
® 's Observed site;(abutting property/observation hole within 150 feet of SAS)
•
❑ Checked with local Board,of Health`-explain:
El Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must°describe how you established the high groundwater elevation:
f
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09/08 r + Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
F Title 5 ®fficialInsp ection Form ,
Subsurface Sewage'Disposal!System Form `Not,for Voluntary Assessments°
G1M
1492 Hyannis Barnstable Road
Property Address '
Edward Razzik
Owner Owner's Name ry
information is
required for every Barnstable MA- 02625 5/11/11
page. CitylTown' - State • Zip Code . Date of Inspection '
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or'E checked—
® Inspection Summary D (System,Failure Criteria Applicable to All Systems)completed
® System'Information- Estimated depth.to high groundwater
®' Sketch of Sewage Disposal System either drawn on page 15 ci,attached',in separate file
•
t5ins•09/08 _ Ttle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
-\ COMMONWEALTH OF MASSACHUSETTS »{`
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
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TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:
qaa �
Owner's Name:
Owner's Address:
Date of Inspection: A�
Name of Inspector: (plea a print) ✓ t �✓� L/1 �—
Company Name: ,
Mailing Address: 40 K 3
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Telephone Number: Q
'CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that.the information i5orted
below is true.accurate and complete as of the time.of the inspection. The inspection was perform�4 based orFFm
training and experience in the proper function and maintenance of on site sewage disposal systems I am a DFP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)..The sysfe n:
/x Passes :X
Conditionally Passes U�
co
Needs Funhe; valuation by the Local Approving Autho ity to
Fails N r+rn
Inspector's Signature: Date: 2—
The system inspector shall submit a copy of this inspection report to the Approving Authurity(Board of Health or
DEP)Nvithi;.i 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*eaional 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
1�
****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.
Title 5 Inspection Form 6/15/2000 page I
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: Z- f l y77�&E�
Owner:
Date of Inspection: -71L467
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 CM R 15.304 exist. An failure criteria n v
y of evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system com onents`as described in the"Condit' "P tonal 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 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
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:
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OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner:
Date of Inspection: z
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has 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 coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner: 2 /C
Date of Inspection: Z
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
P 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.
94� Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
d(- 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
(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 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•
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 withit.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 11 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.
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OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 7 Z i ��
Owner:
Date of Inspection: Z
Check if the following have been done. You must indicate`ves"or"no"as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health
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Were any of the system components pumped out in the previous two weeks?
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Has the system received normal flows in the previous two week period?
_ Have large volumes of water been introduced to the system recently or as part of this inspection?
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage backup?
Was the site inspected for signs of break out?
_ Were all system components S,located on site?
_ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition
bf the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
t _ Was the facility owner(and occupants if different from owner)provided with information on the proper
-intenance 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.
_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
i�unacceptable)[310 CMR 15.302(3)(b)]
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OFFICIAL INSPECTION FORM=`NOT'FOR VOLUNTARY ASSESSMENTS '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM//INFORMATION
.Property Address:
Owner:
Date of Inspection:. U0
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual): /
DESIGN flow based on 310 CMR 15.203 (for le:exam 110 gP d x#of bedrooms :
P )
Number of current residents: 0
Does residence have a garbage grinder(yes or
Is laundry on a separate sewage system(yes oro __ [if yes separate inspection required]
Laundry system insp6no
d(yes o no
Seasonal use: (yes o _ _ 0d _ U 1 M
Water meter readings, if available(last 2 years usage(gpd)): — o-7 331�a
Sump pump(yes o nn :
Last date of occupall- y: (�
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CNIR 15.203): 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: WN
Was system pumped as part of the inspection(yes or no ._
If yes, volume pumped: gallons--How was quantity pumped.determined?
Reason for pumping:
TYPE OF SYSTEM
_
Septic tank,distribution box,soil absorption system
Smgle 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):
Approximate age of all'cpmponents,date installed(if known)and source of information:
' ® /
Were sewage odors detected when arriving at the site(yes o no)
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OFFICIAL INSPECTION FORM—NOT'FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: lqqz /
Owner: 2(
Date of Inspection: 2
BUILDING SEWER(locate on site plan)
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:_(locate on site plan) .
It
Depth below grade:
Material of construction: concrete_metal_fiberglass_polyethylene
—other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate) f
Dimensions: j�L� X S /0 X rO
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: 2
Distance from top of scum to top of outlet tee or baffle: r If
Distance from bottom of scum to bottom of outlet tee or baffle: _
How were dimensions determined: &/ 1YL
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Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of.leakage, etc.):
lorD(Gh v��
GREASE TRAP:_(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
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OFFICIAL INSPECTION FORM—NOT'FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM I,QNFORMATION(continued)
Property Address: Z l4✓lv1
Owner: ;Z-
Date of Inspection:
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_polyethvlene 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: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: r
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 or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
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Page 9 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
/ SYSTEM INF,O"RMATION(continued)
l Property Address: Z !'� ✓I/ ��7/�lvy�
Owner: Z/
Date of Inspection: a O
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why.
Tye /' .
leaching pits, number:_L
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.):
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and confisuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum laver:
Dimensions of cesspool:_
Materials of construction:
Indication of groundwater inflow(_,yes or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
i
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 2
Owner: / 2
Date of Inspection: Z
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_77
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Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
j SYSTEM INFORMATION(continued)
Property Address:
Owner: Z(
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water J v 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 ground water elevation:
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