HomeMy WebLinkAbout3009 MAIN ST./RTE 6A(BARN.) - Health L3009 MAIN STREET, BARNSTABLE
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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
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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
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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