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HomeMy WebLinkAbout3009 MAIN ST./RTE 6A(BARN.) - Health L3009 MAIN STREET, BARNSTABLE A= Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '< 3009 Main St. Rt. 6A Property Address _. Elizabeth A. Donahue Owner Owner's Name information is bl tae, required for every Barns Ma. 02630 10/5/2013 page, City/Town state Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered In any way.Please see completeness checklist at the end of the form. Important When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your 2 cursor-do not Raymond Dumas ( y use the return Name of Inspector key. Dumas Landscape Const. �y Company Name 564 Old Stage Rd. Company Address Centerville Ma. 02632 City/Town State 508-778-0249 S1437 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 16.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority co " 10/5/2013 ' Inspectors sig ture Date 'ra The system inspector shall submit a co of this inspection report to the A ro n Authori, Bd*d Y P PY P P PP 9 .(Y of Health or DEP)within 30 days of completing this inspection. If the system is I shared system has a design flow of 10,000 gpd or greater, the inspector and the system ownel shall subiftit thig report to the appropriate regional office of the DEP.The original should be sent to the syst.,'tem 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. LIU & t5ins•W13 title 5 Official on onn:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Tithe 5 Official Inspection Fora Subsurface Sewage Disposal System Form Not for Voluntary Assessments 3009 Main St. Rt. 6A Property Address Elizabeth A. Donahue Owner Owner's Name Information is Barnstable, Ma. 02630 '10/5/2013 required for every Cityfrown State Zip Code Date of Inspedion B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes, 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 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. 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 Fort:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3009 Main St. Rt. 6A Property Address Elizabeth A. Donahue Owner Owner's Name information is required for every Barnstable, Ma. 02630 10/5/2013 page. City/Town 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(cost.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): 0 ❑ 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 16.303(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 Tole 6 Official Mspecfion Form:Subsurface Sewage Disposal System•Page 3 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments y 3009 Main St. Rt.6A Property Address - Elizabeth A. Donahue Owner Owner's Name information is required for every Barnstable, Ma. 02630 10/5/2013 page. cityfrown 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, [Q The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet.but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to 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 ❑ 1z Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow fts-3113 title 5 Offidal Inspection Form:Subsurface Sewage Doosel System-Page 4 of 17 I Commonwealth of Massachusetts Title t e 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 'yt 3009 Main St. Rt.6A Property Address Elizabeth A. Donahue Owner Owner's Name information is required for every Barnstable Ma. 02630 10/5/2013 page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS cesspool orprivy is belo w high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with.a design.flow of 2000gpd- 10,000gpd. ❑ ® The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Me 5 official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 3009 Main St. Rt.6A Property Address Elizabeth A. Donahue Owner Owner's Name informat for every ion is required Barnstable, Ma. 02630 10/5/2013 ' 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? 0 ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components,excluding the SAS, located on site? 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? ® 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): 5- Number of bedrooms(actual): 4 -DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 t5ins•3H3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 3009 Main St. Rt. 6A Property Address Elizabeth A. Donahue Owner Owner's Name information is Ma, 02630 10/5/2013 required for every Barnstable, page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 1 1000 gallon tank with cement baffles 2 leach pits approx.7x6 with risers and steel covers to grade, see attached page for as built. Number 4 has inlet pipe which I believe comes from other building sewer in basement and has an outlet tee which drains to number 3 on as built, fluid level was below outlet tee on number 4 and is a block cesspool and was um ped as art of inspection. Fluid level in P P p P number 3 was 14 inches below invert coming from septic tank. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: 2011 73000 gallons 2012 59000 gallons ' Sump pump. ❑ Yes No Last date of occupancy:: ' occupied now. p Date CommerclaUlndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons r da d � 9 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: t5ins•3/13 Tft 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3009 Main St. Rt.6A Property Address Elizabeth A. Donahue Owner Owner's Name information is Barnstable, Ma. 02630 10/5/2013 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 12/31/2010 as per owner Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: approx. 1000 gallons from 1 cesspool gallons How was quantity pumped determined? pumpers estimate Reason for pumping: Cesspool, part of inspection Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest i inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. " ❑ Other(describe): Septic tank 1 leach pit and 1 cesspool t5ins•3/13 This 5 Official Inspection form:Subsurface Sewage Disposal System•Page a of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 3009 Main St. Rt.6A Property Address Elizabeth A. Donahue Owner Owners Name information is required for every Barnstable Ma. 02630 10/5/2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components,date installed(if known)and source of information: 1973 as per owner Were sewage odors detected when arriving at the site? 0 Yes ® No Building Sewer(locate on site plan): Depth below grade: 12 inches below grade feet Material of construction: �{cast iron ❑40 PVC ❑other(explain): Distance from private water supply well or suction line: town water comes in at back of house Comments(on condition of joints, venting,evidence of leakage, etc.): All good also 1 more building sewer in left side of basement approx.48"from top of foundation. Septic Tank(locate on site plan): Depth below grade: 18 inches 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: Sludge depth: none t5ins•3/13 Tine 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 i Commonwealth of Massachusetts lritle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3009 Main St. Rt. 6A Property Address Elizabeth A. Donahue Owner Owner's Name information is required for every Barnstable, Ma. 02630 10/5/2013 page. City/Town state Zip Code Date of Inspection D. System Information (cunt.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle none Scum thickness none Distance from top of scum to top of outlet tee or baffle none Distance from bottom of scum to bottom of outlet tee or baffle none How were dimensions determined? dip stick ruler 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 in good condition pumped cesspool as part of inspection Grease Trap(locate on site plan): Depth below grade: feet Material of construction: Q concrete ❑ metal Q fiberglass Q 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 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 f Commonwealth of Massachusetts Title 5 official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 3009 Main St. Rt.6A Property Address Elizabeth A. Donahue a Owner owner's Name Information required for eve Barnstable, Ma. 02630 10/5/2013 every page. City(rown 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.): concrete baffles in fair condition Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons 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 3113 Title 6 official kapection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3009 Main St. Rt. 6A Property Address Elizabeth A. Donahue Owner Owner's Name information is required for every Barnstable, Ma. 02630 10/5/2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No D Box 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 3009 Main St. Rt.6A Property Address _ Elizabeth A. Donahue Owner Owner's Name information is required for every Barnstable, Ma. 02630 10/5/2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: precast septic tank, 1 precast pit and 1 block cesspool Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): all good Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration 1 Depth—top of liquid to inlet invert 4 inches Depth of solids layer 24 inches Depth of scum layer 2 inches Dimensions of cesspool' 6x6 Materials of construction concrete block Indication of groundwater inflow ❑ Yes ® No t5ins•3/13 Title 5 OfWal Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts UTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 3009 Main St. Rt. 6A Property Address Elizabeth A. Donahue Owner Owner's Name information is required for every Barnstable, Ma. 02630 10/5/2013 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.): all looks good 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.): r f 1 t5ins•$113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Forma Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 3009 Main St. Rt.6A Property Address Elizabeth A. Donahue Owner Owner's Name information is required for every Barnstable, Ma. 02630 10/5/2013 C !Town page. itY State Zip Code Date of Inspection D. System Information (cunt.) 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 15ins•3/13 Title 5 Official Irspection Form:Subsurface Sewage Disposal System•Page 15 of 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3009 Main St. Rt.6A .. Property Address Elizabeth A. Donahue Owner Owner's Name information is requires for every Barnstable, Ma. 02630 10/5/2013 page. Cityfrown 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: 29.7 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on.record If checked,date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: as per septic inspection report on record dated 10/26/2000 ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: Topo=47.4-15'contour map=32.4-2.7 adjustment=29.7' You must describe how you established the high ground water elevation: USGS mapping Cape Cod Commission Well Info Jan. 2011 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official hmpection 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 3009 Main St. Rt.6A Property Address Elizabeth A. Donahue Owner Owner's Name information is bl t Barnsae, required for every Ma. 02630 10/5/2013 page. City/rown State Zip Code Date of Inspection E. Report Completeness Checklist ® inspection Summary: A, S, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed 0 System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file r , t5ins•3/13 title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 A-2=53 ' 6" A-3=75 ' v A-4=56 ' B-1=45 ' B-2=48 ' 0 B-3=70' B-4=70 ' L D ��. J 9 A 0 I 0 L 3- # 1 L A 2 N ashy` E A 3 4 MAIN ST. n�' �� cQ79/®S'o Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M 3009 Main St. Rt. 6A Property Address Elizabeth A. Donahue_ Owner Owner's Name information is required for Barnstable, Ma. 02630 2/24/2011 every page. Citylrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the I 5 I„� computer,use 1. Inspector: IIIJJJ only the tab key to move your Raymond Dumas cursor-do not Name of Inspector use the return key. Dumas Landscape Const. Inc. Company Name 564 Old Stage Rd. Company Address Centerville, Ma. 02632 City/Town State Zip Code 508-778-0249 S1437 Telephone Number License Number C> B. Certification a 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 •Z� r Title 5(310 CMR 15.000).The system: tY ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority inspect&s-sigiiature 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. I t5ins-09/08 Tide 5 Official Inspection Form:Subsurface Sewage Dis al System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °�M 5 3009 Main St. Rt. 6A Property Address Elizabeth A. Donahue Owner Owner's Name information is required for Barnstable, Ma. 02630 2/24/2011 every page. Citylrown 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: 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 ' Commonwealth of Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 3009 Main St. Rt. 6A Property Address Elizabeth A. Donahue_ Owner Owner's Name information is required for Barnstable, Ma. 02630 2/24/2011 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): [1 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•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 3009 Main St. Rt. 6A Property Address Elizabeth A. Donahue Owner Owher's Name_ information is required for Barnstable, Ma. 02630 2/24/2011 every page. Citylrown 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 ❑ Y P P Y (SAS) 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_ . El- 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: t **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: 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 '/2 day flow t5ins•09/08 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M 3009 Main St. Rt. 6A Property Address Elizabeth A. Donahue Owner Owner's Name information is required for Barnstable, Ma. 02630 2/24/2011 every page. Cityfrown 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 1.00 feet of a surface water supply or tributary to a surface water supply. ❑ E 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- 101000gpd. ❑ E The system fails. I have determined that one or more of the above failure criteria exist as described in 310 MR 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 El El the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09f08 -Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 �. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3009 Main St. Rt. 6A Property Address Elizabeth A. _Donahue Owner Owner's Name information is required for Barnstable, Ma. 02630 2/24/2011 every page. Cityrrown 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 Z El 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? ❑ Z Have large volumes of water been introduced to the system recently or as part of this inspection? I❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? • ❑ Were all system components, excluding the SAS, located on site? Z ❑ 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 El approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of-bedrooms(design): 5 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 3009 Main St. Rt. 6A Property Address Elizabeth A. Donahue Owner Owner's Name information is required for Barnstable, Ma. 62630 2/24/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 1 1000 gallon tank with cement baffles 2 leach pits approx 7x6 with risers and steel covers to grade see attached page 18 for as built. Number 4 has inlet pipe which I believe comes from other building sewer in basement and has outlet tee which drains to number 3 on as built. Fluid level was below outlet tee on number 4 and fluid level in number 3 was 24" below inlet invert. approx 4 ft of liquid in number 3 Number of current residents: 2 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 ® No Seasonal use? ❑ Yes ® No Water meter readings; if available(last 2 years usage(gpd)): Detail: C'9-60 Co goo a Sump pump? ❑ Yes JE No Last date of occupancy: occupied nowDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ 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 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G1M s 3009 Main St. Rt. 6A - Property Address Eliza4eth A. Donahue_ Owner Owner's Name information is required for Barnstable, Ma. 02630 2/24/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: owner had pumped 12/31/10 Was system pumped as part of the inspection? ❑ Yes No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Reg Maint. Type of System: El Septic tank, distribution box, soil absorption system El Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a'copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval.- Other(describe): septic tank and 2 leach pits t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 3009 Main St. Rt. 6A Property Address Elizabeth A. Donahue Owner Owner's Name information is Barnstable Ma. 02630 2/24/2011 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1973 as per owner Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 12 inch below grade feet Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: town water back of house feet Comments(on condition of joints, venting, evidence of leakage, etc.): all good also 1 more bld. sewer in left stde of basement approx 48"from top of foundation Septic Tank(locate on site plan): Depth below grade: 18 inches 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: Sludge depth: none all water t5ins-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 M 3009 Main St. Rt. 6A Property Address Elizabeth A. Donahue Owner Owner's Name information is required for Barnstable, Ma. 02630 2/24/2011 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle none Scum thickness none Distance from top of scum to top of outlet tee or baffle none Distance from bottom of scum to bottom of outlet tee or baffle none How were dimensions determined? visual dip tank with stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): pumping not needed at this time Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene 0 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 Title 5 Official Inspection Fora, Subsurface Sewage Disposal System Form-.Not for Voluntary Assessments °M 3009 Main St. Rt. 6A Property Address Elizabeth A. Donahue Owner Owner's Name information is required for Barnstable, Ma. 02630 2/24/2011 every 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.): concrete baffles in fair condition Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 3009 Main St. Rt. 6A Property Address Elizabeth A. Donahue Owner Owner's Name information is required for Barnstable Ma. 02630 2/24/2011 every page. Citylrown 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 no d box. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t1ms•09/08 Title 5 Official Inspection form:Subsurface Sewage Disposal.System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3009 Main St. Rt. 6A Property Address Elizabeth A. Donahue Owner Owners Name information is required for Barnstable, Ma. 02630 2/24/2011 every page. Citylrown State Zip Code Date of Inspection D. System information (cont.) Type: 2 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.): all ok 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•09168 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 3009 Main St. Rt. 6A Property Address Elizabeth A. Donahue Owner Owner's Name information is Barnstable, Ma. 02630 2/24/2011 required for i 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.):- all good 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M 3009 Main St. Rt. 6A Property Address Elizabeth A. Donahue Owner Owner's Name information is required for Barnstable Ma. 02630 2/24/2011 every 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 ® drawing.attached separately t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M 3009 Main St. Rt. 6A Property Address Elizabeth A. Donahue Owner Owner's Name information is required for Barnstable, Ma. 02630 2/24/2011 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar Shallow wells 29.7 Estimated depth to high ground water: feet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: as per septic inspection report on record dated 10/26/00 ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: topo=47.4-15'contour map=32.4-2.7 adjustment=29.7' You must describe how you established the high ground water elevation: USGS mapping Cape Cod Commission Well info jan 2011_. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5in5.09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 3009 Main St. Rt. 6A Property Address Elizabeth A. Donahue Owner Owner's Name information is required for Barnstable, Ma. 02630 2/24/2011 every page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checkli$t f. E 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•09108 Titre 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 A-1=52 ' A-2=53 ' 6" A-3=75 ' A-4=56 ' B-1=45 ' B-2=48 ' B-3=70 0 B-4=70 tF' B L D 9 A 0 I 0 L #3 1 L A 2 N o E . A 3 a MAIN ST. �� jS COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL,AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION 0 s� TITLE 5 OFFICIAL, INSPECTION FORM OR SUBSURFACE SEWAGE DSPOSAAILSY SYSTEM FOTARY A RM PART A RM CERTIFICATION Property Address: 3oog main St-.- Owner's Name: STJB�01e Ma �� Owner's Address. p,0: '°° 4/ �r 91012 S.Waloole Ma o?n-7 Date of inspection: t s�. Name of Inspector: (please print) 41AfA�r�- ?000 Company Name: P ) KQvi n p Mailing Address: eM Grove Street Telephone Number: WrW MA 02346 CERTIFICATION STATEMENT � 7-�213 I certify that I have personally inspected the sewage disposal system at this address and that the information report below is true,accurate and complete as of the time of the inspection.The inspection was performed based on m ed 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 Needs Further Evaluation by the Local Approving Authority Fail Inspector's Signature: �C :-r ��. ,. Date: C1"Z `� - o o The system inspector shall submit a copy of thi DEP)within 30 days of co s inspection report to the Approving Authority(Board of He alth or mpleting this inspection. If the system is a shared system or has.a design flw of 10 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional o o ffice of th0 00 e DEP,.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report onlydescribes ibes conditions at the time of use at that time.This inspection does not address Flow the system will perform inthe future underunder thettions the same or different conditions of use. Q- Title 5 Inspection Form 6/15/2000 page I Page 2 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 3009 Main St Owner: Barns ab1P Ma �IIBp--�� Date of Inspection: i n 1,)r n n Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15 3303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the 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: 2 Page 3 of I l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: $arn�tabjj Ma Owner:S 1B hn Date of Inspection: n 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 ally)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. Y _ 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 colifon.n 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: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 3009 Main St. Barnstable Ma . Owner: SURON CO Date of Inspectioa: 1 0/2 h/00 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 %day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 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. f 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 6—MR 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 within 200 feet of a tributary to a surface drinking water supply _ — the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST . Property Address: 3009 Main St . Barnstable Ma. Owner: SUB0N CO. Date of Inspection:10j 2 6/0 d Check if the follow', III ing have been done. You must indicate"ves"or"no"as to each of the following: Yes No .X— _ Pumping information was provided by the owner,occupant, or Board of Health X Were any of the system components pumped out in the r o prev ious ous two weeks XHas the system received normal flows in the previous two week period? XHave large volumes of water been introduced to the system recently or as part of this inspection? V Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS, located on site? X _ 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? . X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X Existing information.For example,a plan at the Board of Health.. X _ Determined in the field(if any of the failure criteria related to Part.0 is at issue approximation of di is unacceptable)[310 CN M 15.302(3)(b)) stance 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 3009 Ma in St. Owner: SUBON Co. rnstable Ma . Date of Inspection: 10 RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design): Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 0 Does residence have a garbage grinder(yes or no): no Is laundry on a separate sewage system(yes or no): no [if yes separate inspection required] Laundry system inspected(yes or no):_ Seasonal use: (yes or no): Water meter readings, if available(last 2 years usage(gpd)): 19 9 9=4 7 0 g p d 19 9 8=312 gp d Sump pump(yes or no): no Last date of occupancy: -27 0 0 COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): d 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): Pumping Records GENERAL INFORMATION Source of information: Homeowner pumped twice in last 4 yrs. Was system pumped as part of the inspection(yes or no):no If yes, volume pumped:_.gallons--How was quantity pumped determined? Reason for pumping: . TYPE OF SYSTEM X Septic tank,--disttihetieehcW,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract to be obtained from system owner) Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: + rs Were sewage odors detected when arriving at the site(yes or no). no 6 Page 7 of 11 OFFICIAL,INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 3 0 0 9 Main St. Barnstable Ma Owner: �n Date of Inspection:ip/2 h/n 0 BUILDING SEWER(locate on site plan) Depth below grade: 12" Materials of constructio xx cast ast 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: x (locate on site plan) Depth below grade: 18" Material of construction: x concrete other(explain) metal fiberglass__polyethylene _ If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 8 'x 4 'x 5 ' ( 10 0 0 gals. ) Sludge depth: 4°' Distance from top of sludge to bottom of outlet tee or baffle: 2 0" Scum thickness: 1 Distance from top of scum to top of outlet tee or baffle: 8 Distance from bottom of scum to bottom of outlet tee or baffle: 15" How were dimensions determined:_ In f; P l Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Tank and cement baffles in good condition, liquid level with outlet no si ns of leaka e 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 scrum 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.): 7 Page 8 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 3009 Main S •�T1RONt. AarnGtar e M� Owner: (�n Date of Inspection: 0 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: allons Design Flow: allons/day Alarm present(yes or no): Alarm level: Alarm in workingorder Date of last pumping: (yes or no): 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: 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.): 8 Page 9 of 11 i i OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: RarnstahIP Ma Owner: 4iTRC1 T nn Date of Inspection: 1— SOIL ABSORPTION SYSTEM(SAS): x (locate on site plan,excavation not required If SAS not located explain why: Type x 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.): This sas consists of 1 6x6 pit with a 7x6 overflow for pi o pi s a.re in in eit er goo con i ion. ere is no iqui CESSPOOLS: (cesspool must be pumped as part of uispection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY; (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C - SYSTEM INFORMATION(continued) / Property Address: 3009 Main St. Owner: SUR Barnstable Ma. Q T CO Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. A-1m52 ' A-2=53 ' 6" A-3=75 ' A-4=56 ' B-1=45 ' B-2=48 ' B-3=70 ' B-4=70 ' 0 JB L D 9 J 0 A 0 I #3 L 1 L 2 A N A E 3 4 MAIN ST. 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 3 0 0 9 Mai n Barnet-ah1 P Ma Owner:—STTR(lnr nn Date of Inspection: I n/�g�lno _ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet no water found at 10+ , 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: x 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: Checked FEMA maps , maps indicate hi a h level at 15 ' low t 40 ' I1