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HomeMy WebLinkAbout2360 MAIN ST./RTE 6A(BARN.) - Health s�- 2-7 _ Barnstable A= 237 — 020 r =� Commonwealth of Massachusetts Tile 5 Official Inspection Form L Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments '~ 27 4 d"e'Lane v _,,,Property 3�G M�^1 ^ 1 Jf: ropertyAddress Dorothea Dodge< 'Owner Owner's Name information is Barnstable MA 02630 02/10/08 .. required for eve a e. City/Town State Zip Code Date of Inspection p ry 9 Inspection results must be submitted on this form. Inspection forms may not be altered in any way s - When filling A, ,,General Information When filling out' �. , forms on the computer,use J 1. Inspector: only the tab key to move your ,Michael Kellett . cursor-do not { Name of Inspector " use the return z key. Aardvark Environmental Inspections �• Company Name . P.O. Box 896 Company Address + East Dennis MA 02641 Cityffown State Zip Code 508-385-7608. S13742 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: Z Passes ❑ Conditionally Passes ❑ Fails '" ❑ Needs Further Evaluation by the Local Approving Authority t �. . 02/14/08 + Inspector's Signature y_ Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board }i of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or " f 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 Y and copies sent to the buyer,if applicable, and the approving authority. F ***This report only describes conditions at theaime 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. . Y v n fail°08108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System°Page 1 of 15 .. if= .t, • .. f ., •¢• •. .- � t •. '4 - .. � 'Commonwealth of Massachusetts ..' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form,Not for Voluntary Assessments '< 27 Dodge'Lane Property Address Dorothea Dodge Owner Owner's Name' information is Barnstable MA 02630 02/10/08 required for every page. Cityrrown State> Zip Code Date of Inspection B. Certification (coat.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: z I.have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. ' Comments: B) System Conditionally"Passes: One or:more system components as described in the"Conditional Pass"section need to be, replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined (Y, N, ND)in the R for the following statements. 1f"not } determined," please explain. 0 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: r 0 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): �a broken pipe(s)are replaced Ej 'obstruction is removed ' fail•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 t1 ly: t Y ` •` gia ' a �- ..Commonwealth of Massachusetts lk KTitle 5 Official. lnspccti®n;f®rrn Subsurface Sewage Disposal System Form Not-for Voluntary Assessments 27 Dodge Lane " Property Address Dorothea Dodge Owner Owner's Name information is Barnstable required for <` . -'MA ' 02630 02/10/08 every page. Cityfrown '-: State Zip Code. Date of Inspection , B. Certification (coot ) B) System Conditionally Passes (cont.): 3 distribution box is leveled.or replaced Y ~ ND Explain: "A a- 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 pipes)are replaced , ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board`of Health: Condit1.ions 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 nanner which will protect public health, safety and the environment. icy ° .. -:i • i�F ..,. r �d3. .t } x ., f E $, 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 fall 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. r The system,has aseptic tank and SAS and the�SAS is within a Zane 1 of,a public water supply.: k The system has a septic tank and SAS and the,SAS is within:50'feet of a privatewater t supply well. 4 " fail•08106 z Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 . Commonwealth of Massachusetts u Title 5 Official Inspection,.Form o Subsurface Sewage Disposal System.Form-Not for Voluntary Assessments 27 Dodge Lane Property Address Dorothea Dodge Owner Owner's Name information is Barnstable MA 02630 02/10/08 required for State Zip Code Date of Inspection every page. Cityrrown B. Certification (cont.) C) Further Evaluation is Required by the Board'of Health (cont.): ❑ 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 welly*. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified 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: r 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 Ej 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 %day flow Required pumping more than 4 times in the last year NOT due to clogged or 0 z 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. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 fail•08/06 Commonwealth of Massachusetts T y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 27 Dodge Lane Property Address Dorothea Dodge Owner Owner's Name information is required for Barnstable MA 02630 02/10/08 every page. Cityfrown ;' State• Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cunt.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] , ® ;'The system_is a cesspool serving a facility,with a design flow of 2000gpd- 10,000gpd. ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct.the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ the system is within 400 feet of a surface drinking water supply the system is within`200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection ❑ - Area=1WPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section Ethe 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. fail•08/06 Title 5 Of icial Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 27 Dodge Lane . Property Address Dorothea Dodge Owner Owners Name information is required for Barnstable MA 02630 02/10/08 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® { '❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of 0 ® 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? Z ❑ Were all system components,excluding the SAS; located on.site? 0 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? ® ElWas 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)] fail•08106 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 27 Dodge Lane Property Address Dorothea Dodge Owner Owner's Name information is required for Barnstable MA 02630 02/10/08 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 7 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 220 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a-separate sewage'system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes 0 No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Sump pump? ❑ Yes ® No Last date of occupancy:.. Date ' Date Co_mmercial/Industrial Flow Conditions: Type of Establishment: Design flow.(based on 310 CMR 15:203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 fail•08/06 D f Commonwealth of Massachusetts F Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments s• 27 Dodge Lane Property Address ` Dorothea Dodge Owner Owner's Name w ' information is required for Barnstable MA 02630 `02/10/08 . every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) . t t General Information- . _ • ,. • F t Pumping Records: P Source of information: JWas system pumped as part of the inspection? ❑ Yes 0 No If yes, volume pumped: .'gallons -,How was quantity pumped determined? Reason for pumping: - Type of System: Z Septic tank, distribution box, soil absorption system y [] Single cesspool' ❑ Overflow cesspool ❑. Privy ❑. s- 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): y` Approximate age of.all components, date installed (if known)and source of information: ;20 years 8 Were sewage odors detected when arriving at the site? ❑ Yes ® No Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 fail•08J08 P 9 sPo Y 9 Commonwealth of Massachusetts - Title 5 Official Inspections Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 27 Dodge Lane. Property Address ° Dorothea Dodge Owner Owners Name information is required for Barnstable MA 02630 02/10/08 every page. Cityfrown State, Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site.plan): Depth below grade: 3.2 P 9 feet Material of construction: ` 4 . . ❑ cast iron ❑40 PVC ®other(explain): orang eburg pipe 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): Depth below grade*.' 2.4 feet Material of construction:. 0 concrete ❑ metal ti, ❑fiberglass ❑,polyethylene ❑other(explain) 1 If tank is metal, list age: ,: years t Is age confirmed by,a Certificate of Compliance?,(attach a'copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal _ _ 3„ - Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 2911 Scum thickness 7, Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 16" measured How were dimensions determined? fail•08/06 ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection- Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 27 Dodge Lane Property Address 4 Dorothea Dodge Al Owner Owner's Name information is required for Barnstable MA 02630 02/10/08 every page. Cityfrown State Zip Code Date of Inspection D. System Inf ormation cost. Comments(on pumping recommendations,.inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was sound and tight with tees in place and liquid at outlet invert. n site Ian Grease Trap locate o ., ( plan): . Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): " I 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 td Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): a 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): fail•08106 Idle 5 Official Inspection form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 27 Dodge Lane Property Address , Dorothea Dodge Owner Owner's Name information is Barnstable MA 02630 02/10/08 required for stater Zip Code Date of Inspection every page. Cityrrown D. System Information (cont.) . ' Tight or Holding Tank(cunt.) 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 Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments(note if box is.level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): no box present Pump Chamber(locate on site,plan): ,Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Title 5 official inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 fail-08106 f Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 27 Dodge Lane ' Property Address Dorothea Dodge Owner Owner's Name information is required for Barnstable MA 02630 02/10/08 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: o Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 1 @3'x26' ❑ 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.): This system has a stone lined trench that is 3 feet wide by26' long. There was no sign of ponding or failure. fail•08/06 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 27 Dodge Lane Property Address Dorothea Dodge Owner Owner's Name information is Barnstable MA 02630 02/10/08 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): fail•o8/06 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 27 Dodge Lane Property Address Dorothea Dodge Owner Owner's Name information is required for Barnstable MA 02630 02/10/08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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, (�c,\Ic fail•08/06 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts Title 5 Official- Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 27 Dodge Lane Property Address Dorothea Dodge Owner Owner's Name information is Barnstable MA 02630 02/10/08 required for ' every page. CitylT•own State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water x ® Check cellar s a Shallow wells . Estimated depth to ground water: feet feet Please indicate all methods used to determine the high groundwater elevation: - ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) Accessed USGS database explain: , You must describe how you established the high ground water elevation: USGS maps Show an elevation of over 25 feet fail•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 1HE Town of Barnstable �p Tp� ti Regulatory Services Np O BAMSTABLE ; Thomas F. Geiler, Director prFa��A Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future not does this Division agree with any technical observation s and interpretations contained within this report. In addition,by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the "Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection.