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Home My WebLink About0567 MARSTONS LANE - Health 567 Marstons Lane Barnstable, MA A__ . -- O MONW -LT111-OF MALSSA" C�_ISET'i's ... EXECUTIVE OFFICE OF ENVIRONMENTAI.AFFAIRS _ DEPART {'' ; i�� " a'i { t;LE MEI�TT OF ENVIRONMENTAL IsCTION r TITLE 5 OFFICIAL INSPECTION FORM—NOT SUBSURFACE SEWAGE DISPOSAL S STEM FORMNTARY ASSESS MENTS PART A CERTIFICATION Property Address: 5 at Owner's Name: wt Owner's Address: Date of Inspection: t - I Name of Inspector:(please print) j C QC G` �' Company Name:!?n r-.)�✓.t&, . . Mailing Address: 0 Telephone Number:-- �+ > A 09-641 CERTIFICATION STATEMENT ' I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of 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 15340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature- �Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or. DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of I0,000 ' 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. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different , conditions of use. Title 5 Inspection Form 6/15/2000 pane I r Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) i Property Address: -1,7 lif y-Ir_ Owner: d'kt a Date of Inspection e 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 des crib 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. d 310 CMR 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 state .If`' of determined"please explain. The septic tank is metal and over 20 years old*or the septi (whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank ure is imminent System will pass inspection if the existing tank is replaced with a complying septic tank as' oved by the Board of Health. *A metal septic tank will pass inspection if it is stru y sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is a ble. ND explain: ,. Observation of sewage backup o reak out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a brok tiled or uneven distribution box.System will pass inspection if(with approval of Board of Health): broken pipe(s)amen obstruction is zzmoved distribution boot is bled or replaced ND explain: The sy required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass mspe ' n if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of I 1 OFFICIAL,INSpEC;IpN FORM_NOT FOR VOLUNTARY SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOB TS PART A CERTIFICATION(continued) Property Address: S6 7 goo* YlS Owner: Date of Inspection: G a o C• Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of th in ord is failing to protect public health,safety or the environment. er to Bete rmtne,ifthe system 1• System will pass unless Board of Health determines i ccordance with 310 system is not functioning in a manner which will pr ect public health,safety and he environment: that the ,_ Cesspool or privy nvtronment. P vy is within 50 feet of a s e water ____ Cesspool or privy is within 50 feet of a b Bering vegetated wetland or a salt marsh 2. System will fait unless the Boar of Health(and Public Water Supplier,if any)deter system is functioning in a manner at protects the public health,safety and environment: that the _ The system has a septic and soil absorption sstem(SAS)and the SAS is within 100 feet of surface water supply or trio Lary to a surface y water supply. _ The system has a s tic tank and SAS and the SAS,is within a Zone I of a public water sup,l . t, PY _ The system has septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more.from a Private water su ly well**.Method used to determine distance **This syste passes if the well water analysis, coliform bacteria and olatile organic compounds indicates that the well iiss EP free from Pollutcertifiedtiion ratory fromothatt facility and the presen of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure eria are triggered.A copy ofthe analysis must be attached to this form. 3. Ot er: I 3 r Page 4 of l l OFFICIAL INSPECTION FOR 1Vl—NOT-FOR VOLUNTARY ASSESSMENT'S s: SUBSURFACE SEWAGE SA"YSTEM INSPECTION FORM d PART.A CERTIFICATION{continued) Property Address: s6 7 P(G�ru`Fi Owner. v Date of Inspection: p D. System Failure Criteria applicable to all systems: You must indicate"yes',or-no-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 A_L Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than''/z day flow -Y- Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped -4 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. 0( 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.ffbis system passes if the well wateranalysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic-comp€unds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to-or less than s ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.) Nv (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a dMign flow of 10,000 gpdi 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 criteria above) yes no — _ the system is within 400 feet of a e drinking water supply . — _ the system is within 200 feet a tributary to a surface drinking water supply the system is located' a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone H of a publi supply well If you have answered' es"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D ove the large system has failed.The owner or operator of any large system considered a. significant thr der Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The stem owner should contact the appropriate regional office of the Department. n PageS of : OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F®RM PART B CHECKLIST Property Address: 7dl�SrLS Owner-. Date of Inspection• 6 (0 O) 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 X 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? a 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? _ 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 manitenance of subsurface sewage disposal systems?. , The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _ Existing information.For example,a plan at the Board of Health. _ Determined in the field(if any of the failure criteria related to Part Cis at issue approximation-of distance is unacceptable)(310 CMR 15.302(3)(b)] v Page 5 off 1= OFFICIAL INSPECTION FORM'--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address 6 �ar Owner: Date of Inspection: FLAW CONDITIONS RESIDENTIAL Number of bedrooms(design): 9' Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: pZ Does residence have a garbage grinder(yes or no): Ab Is laundry on a separate sewage system(yes or no):- (if yes separate inspection required] Laundry system inspected(yes or no): 0J0 Seasonal use:(yes or no):&p Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): IVc� Last date of occupancy: GG V_ v " COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(/eae 310 CMR 15.203 spd Basis of desiseats/persons/ ,etc.): Grease trap pes or no): Industrial wag resent(yes or no):—Non-sanitary c ged to the Title 5 system(yes or no): Water meter r ' available:Last date of o /use:OTHER(des u GENERAL INFORMATION . Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): A If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM K 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) _Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: 'g 0Ai Were sewage odors detected when arriving at the site(yes or no): I1�0 6 Page 7 of I l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 7 q40 ! Owner: Date of Inspection: BUILDING SEWER(locate on site plan) . Depth below k grade: Materials of construction:_cast iron /40 PVC Distance from private water supply well or suction line:other(explain): Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:a(locate on site plan) Depth below grader Material of construction: concrete metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ is age confirmed by a Certificate of Com liance certificate) p (yes or no):_(attach a copy of Dimensions:_[ 4 Sludge depth:—�. Distance from top of scud e o bottOmf outlet tee or baffle: Scum thickness:__Q___ Distance from top of scum to top of outlet tee or baffle: UO u Distance from bottom of scum to bottom of outlet tee or b ffle: r How were dimensions determined:—� 5 y Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related}outlet invert,evidence of leakage,etc.): ie ca01-J GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal fiberglass (explain): _polyethylene_other Dimensions: Scum thickness: Distance from top of scum to top o utiet tee or baffle: Distance from bottom of scum t ottom of outlet tee or baffle: Date of last pumping; Comments(on pumping re mmendations,inlet and outlet tee or baffle condition,,structural integrity,liquid levels as related to outlet inve evidence of leakage,etc.): f age8of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: �� Owner:-� Date of Inspection• o 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: allo Design Flow: ons/day Alarm present(yes or no): Alarm level: Al working order Date of last pumping: g (yes or no): Comments(condition o alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:_2 VeN, Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage!-9jo or out of box,etc.): /I 1 fkc /O ox .c r f e use a�u Al 1 tG GJ l i (�►o s t4 B-} GGc/y c.c�JPA. (PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no):. Alarms in working order(yes or no): Comments(note condition of p chamber,condition of pumps and appurtenances,etc.): 8 _Page 9 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSUkFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 56 Owner- Date of inspection: �0 05— SOIL ABSORPTION SYSTEM (SAS): locate on site plea,excavation not required) If SAS not located explain why: Type 0< leaching hmoo Pits,>num ber leachingcha mbers, number mber. leaching galleries,number leaching trenches,number, length: Ieaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Continents(note condition of soil,signs of hydraulic fail etc.): ure,level of ponding,damp soil, condition of vegetation, CAP- Qto 6lc�VQ� 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 ofconstmcti Indication of groan ater inflow(yes or no): Comments(note ndition 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 con ion of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.): 9 Page 10 of i l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: S67 t��Sky Owner: Bate of Inspection: p SKETCH OF SEWAGE WSPOSAL 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_ s' vo �5- 3 r Page I I of I I OFFICIAL. INSPECTION FORM—'=SOT FOR VOLUNTARY ASSESSMENTS SUBS€1RFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: � �� Owner: Date of Inspection: SITE EXAM Slope YP5 Surface water 600 Check cellar tV5 Shallow wells 14)0 Estimated depth to ground water_3 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed:_ Observed site(abutting property/observation hole within I50 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) OC Accessed USGS database-explain: You must describe how you established the high ground water elevation: s CJ S 1Ma S C ll