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Home My WebLink About1242 MARY DUNN ROAD - Health Fr12-42 Mary Dunn Road L :�stable 334-038 C) k' h 0 'il . - ®3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments /Q`) `O` ///��it ✓ 00� h (� Property Address innfforn*on is qer ON ner s Name J� �� O� �,�p required for every G r [ r page. Ckytrown State Zip Code Date of Inspection lug 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. lee Irn g portent en A. General Information ,S fffig� on the computer, use only the tab 1. Inspector key to move your cursor-do not Cy /o�j e, use the return key Name of Inspector j/1/1 // O Company Address Cdy/Town Ls �g0 /P �o state / 'D i� Zip Code Telephone Nurhber License Number B. Certification 1 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;"101116.000). The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Need Further Evaluation by the Local Approving Authority aig hspecto s Signahre Date The system inspector shell 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 authodty. ****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. t9no• $ 5 mffidalInspecton Form subwface Sewage Dlspoad System•Page 1of17 • ' Commonwealth of Nlassachusetts 1M1 Title 5 Offilq al Inspection Form Subsurface Sewage. Dl=i al System Form -Not for Voluntary Assessments / Property Address ON ner Ow nets Name information is ✓✓, Y4,4 /� do)(,3t7 '5 requiredforevery page. �'frown State Zip Code Date of ktspection pa B. Certification (corn) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System sees: 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 ex ain. The septic tank is metal and over 20 years old" or the septic tank(whether metal or not)is structurally unsound, exhibits subsIantial infiltration or exfiltration or tank failure is imminent. System will pass Inspection if the existino tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank WO pass inspection if it is structurally sound, not leaking and If a Certiflcate of Compliance indicating that the tank is lees than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): 1 Title 50ltldal ire pecten F orm Subsulme Sewage Disposal System•Page 2 of 17 19re•3113 I Commonwealth of Massachusetts Tile 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments /) q";,2— a Y-,? Property Address &V� i formation is ON ner's Name r✓I y / � Od-G 3 o b required for every State Zip Code Date of insp6etion page. Cityyfrown B. Certification (coat.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(coat.): ❑ 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 ❑ NO(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO(Explain below): ❑ 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 ❑ NO(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 wol pass unless Board of Health determines in accordance with 310 CMR 16.303(1)(b)that the system is not functioning Ina mannerwhich 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 T106 50MG101 impec0or F CrM subeu j0ce sewage otevwd syAom-page WV t9rie•3fl3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewagel Disposal System FormmJ-Not for Voluntary Assessments /cam Td� i' �(�✓ .U�, ►�h 12 ` Property Address ri Ow ner ON ner's Name infonreft Is ✓h S jG /g Od 6�y requirM for every 3AIT page. City/Town State Zip Code hate of ldspecWn B. Certification (conl.) 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 sal absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS Is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for 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 iiij 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 us 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 Uquid depth In cesspool Is less than 6"below invert or available volume Is less Cl than%day flow SM,M Ti6e 6010CW UspWtM F amt SubsWam Sewage DiepoW System•Page 401 V Commonwealth of Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage))Disposal System Form-Not for Voluntary 'Asnssessments I� Properly Address ON nor ON noes Mirre ) / / information Is �c/n ST'► b�t ad'4 required for every page. Cityfrown State. Zip Code Date Ins tan B. Cerfification (coat.) Yes No ❑ ��Any //1" Required pumping more than 4 times in the last year NOT due to clogged or ob structed pipe(s). Number of times pumped:ped:❑ 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 1 of a public well. ❑ ny 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 S ppm, provided that no other failure criteria ate 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 kill . I have determined that one or more of the above failure cnteda exist as described in 310 CMR 16.303, 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 Ifyou 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 16.304. The system owner should contact the appropriate regional office of the Department. Oro 313 Titl SOMCISI lmpxtlmFarM SuCs+la0&s&v goojsposd syom•Pago 6017 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for voluntary Assessments Property Address ��J c i�v(Gt Y/R Cw ner ON ner's Nar►,e lnfornvatbn oa 63� required f or every page• Olyrrown 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 foilowing: Yes o ❑ umping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? ❑ s 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? ❑ 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 i been determined based on: [9' ❑ 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)1310 CMR 15.302(5)) D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): 33o . DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): ------- tft Y13 Tide SOftldelImpectfonFormSubavfewSewge0leposd%*m•Page$of17 I Commonweab of Massachusetts Title 5 Official Inspection Form Subsurface Sewage [Disposal System Form --Not for Voluntary Assessments Q Property Address innffommmUm Is av ner's Name 1111 �o� �D3 All Iredforevery tky/Town 6 k State Zip Code Date of Inspection D. System Information Description: / /C d U / , `�o h JP t° ` / L jGs7/rorr �0-;,5/ Number of current residents: a- -No residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system?(Include laundry system Inspection ❑ Yes ❑--*N--o information in this report.) Laundry system inspected? ❑ Yes Be No Seasonal use? ❑ Yes ;XNo Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes No Last date of occupancy: pate Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM R 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: Farr suba0we ODl s m-Fags�m�T c51re-ens Tine50fNcial Mspacdan Seweg apasA yeas i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth -Not for Voluntary Assessments /� �oL A4� 0 W1 �Cl Property Address - ow M owners Name 1 infomvatlon is required for every Pa" C /Town State Zip Code Dete of Inspectbn D. System Information (cola.) Last date of occupancy/use: Dete Other(describe below): General Information Pumping Records: Source of information: system pumped as part of the inspection? ❑ Yes No Wass ys . If yes, volume pumped: ganon How was quantity pumped determined? Reason for pumping: Type 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 Inspection of the VA system by system operator under contract Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): tbiro•3n3 t sae 60fWal ftpadan F arm Subsutaw SewageDlepaoel$YOM•Pepe Of 1T �r Commonwealth of Massachusetts IVTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments A�e4'v- 411 Property Address ON ner information Is Owner's Name 1 L required for every ✓�S page. Cdy/Town State Zip Code Date of spec n D. System Information (corn.) b Approximate age of all components, date installed Of known)and source of information:: Were sewage odors detected when arriving at the site? ❑ Yes G�No Building Sewer(locate on site plan): Depth below grade: feet Material of constructi;40-P�vc ❑ cast iron ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Material 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: ':7 8 Sludge depth: SM-M3 Tine sorflael mspecem Famm Sucavraoe Sewage Disposal System•Page 9of17 Commonwealth of Massachusetts Title 5 Official Inspection Forum Subsurface Sewage Disposal System Form -Not for Voluntary Assessments `� 7r�- i��'/G� ✓1 cal /'�C Properly Address Cw ner av Hers IVarne information is required for every page. Ctylrown State Zip Code Date of Inspection D. System Information (cunt.) Septic Tank(coat.) Distance from top of sludge to bottom of outlet tee or baffle 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 How were dimensions determined? all- Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural Integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap Qocate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Ore•3M3 Tme50Mdd UspectmFom SubWaw SewageDlspow SYMM.Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments /C� Ll _aki 2� property Address u�� ON ner nears Name L / l infornwatlon is q.h sT-"►b C �•¢ oo��O3o .s.L_._ required for every page. Cky/row n State Zip Code Date of Inspection D. System Information (writ.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 woridng 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 �t3 Tile60Nwdd M9pao6wForm SubMAWOSOOMODwep O Spism�Pigs 11 d 17 Ors5 1 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not tttfffor voluntary Assessments �cf � // /C�✓ /it✓�vI Property Address 11*4 t/,/'::t&-7 om lnf Her Ow noes Name iM l��6�f7 J j•^ om�n� l ` required for every Rown a/✓rS 7 State Zip Code Date of spectiori Me. City frown System Information (cont.) 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.): do >/, :,fie✓mil /IT 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)Qocate on site plan, excavation not required): 9 SAS not located, explain why: Ons•3H3 Title$0MCid bupeolonFarM SuCe we Se"001WW 3YMM•Page 12 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage))Disposal System Form •Not for voluntary Assessments /C � V p; 'Ilya✓ 6�a kin WCl/ Property Address r Z41& Mumvmon revery ow g rn ►6 /� (�a 63� �� •_ page. Cky/Town State Zip code We of Inspection D. System Information (coat.) Type: leaching pits number. ❑ leaching chambers number. ❑ leaching galleries number.' ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovative/aitemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of. vegetation, etc.): 14110 C Y/ sqf O >< 4 /a v li c 74� t 11t re. 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 One•3n3 Title 50f4dd bupeaknFomc SubsWece Sev"eDispcsd syMm•Pepe 13 d 17 v Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address ON ner ow noes Name h quire fo is --Tr- ✓1 S reufred for every page. Cilly/rown State zip Code Date of Inspection D. System Information (conL) 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 sal, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): am-313 TMSOPodal bBpectlmForm Substrtace SewapeDispcW System-Pape 14 d 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage)Disposal System Forthm Not for Voluntary Assessments Property Address ON nor Ow s Name informOon is required for every /9G✓r1 S ✓ " �7 page. C1 yttwin State Zip Code Date of Inspection D. System Information (cunt.) Sketch Of Sewa Disposal System. Provide a view of the sewage disposal system, including ties to at least two manent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where is water supply enters the building. Check one of the boxes below. hand-sketch in the area below ❑ drawing attached separately I a I 113- -7 YJ d3- tans•Y13 Title 50ffidal Ina pectlon Form Sub9W we Sev4e DispaW System•Pape 15 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Formm Not for Voluntary Assessments Property Address v� information is Owner's Name / requinxiforevery ✓✓)S��S le, �/4 Ov�010 page. Ctyfrown State Zip Code Date of Inspection D. System Information (cost.) Site Dram ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Cam` C) � Estimated depth to high ground water. 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: We ❑ Observed site(abutting property/observation hole within 150 feet of SAS) L9� Checked with 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: o Av'1-7 O 7 (0'c./ :5 X Before filing this Inspection Report, please see Report Completeness Checklist on next page. tsro-3R3 Title 6 OfkW km pectian F arm Sub m0ace Sewage DLV*s t Syabam•Pepe 16 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments ZP1AV-6j ✓r ✓� Property Address A�4 Y,/ ow M per Ws Nwp 9 Monration is Mpdradfarevery POP. !Town State Zip owe Date of hspedbn E. Report Completeness Checklist M Nspection Summary: A, B, C, D, or E checked Ly'bispection Summary D(System Failure Criteria Applicable to All Systems)completed "stern h*nnation—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate>ile f Sm-Y13 TMo5Ctfi l rapleftFam SvMV80e Seue OMP.W t8IWM*PW n of 17 y �rtt1E Town of Barnstable Office: 508-862-4644 Regulatory Services Department Fax: 508-790-6304 BARN 37A0 Public Health Division Thomas A.McKean,CHO 200 Main Street Hyannis, MA 02601 Payment Receipt ',Septic Inspection Payment received: $25.00 (Check) on 5/13/2015 Permit number: 10863 Check number: 1395 Check amount: $25.00 Name on check: Victoria Ann Murray Owner: VICTORIA A MURRAY :Address: 1242 MARY DUNN ROAD, Barnstable Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1242 Mary Dunn Road Property Address Carol Kirkland Owner Owner's Name information is required for every Barnstable MA 02630 4/17/11 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. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: _ key to move your cursor-do not Carmen EShay use the return Name of Inspector Y Shay Environmental Services, Inc. reb Company Name 185 h m 8 s u et Road Company Address Mashpee MA 02649 City/Town State Zip Code 508-539-7966 3080 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant'to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails -0 ❑ Needs Further Evalu n by the Local Approving Authority ' ' 77 4/17/11 Inspector's Signat Date The system inspector shall submit a c py 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. V" 1242 Mary Dunn Road,West Barnstable,MA•03/08 Title 5 Official Inspection Form Subsurface Sewage Disposal Syste •Page 1 of 15 1 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1242 Mary Dunn Road Property Address Carol Kirkland Owner Owner's Name information is required for every Barnstable MA 02630 4/17/11 page. City/Town 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: leach pit has 3 feet of liquid. 2' effective depth available per stain Line Risers present-Tank is 2' and Leach pit is 4 feet below grade. 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.di"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 replace_d 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 lessthan 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due s 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 1242 Mary Dunn Road,West Barnstable,MA•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 1'5 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1242 Mary Dunn Road Property Address Carol Kirkland Owner Owner's Name information is Barnstable MA 02630 4/17/11 required for every , page. City/Town State Zip Code Date of Inspection B. Certification (cont.)' B) System Conditionally Passes(cone.): ❑ 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: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 1242 Mary Dunn Road,West Barnstable,MA-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 1242 Mary Dunn Road Property Address Carol Kirkland Owner Owner's Name information is Barnstable MA 02630 4/17/11 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 9 C) Further Evaluation is Required by the Board of Health (cont.) ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No 3- ❑ ® 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 ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: 0 ® 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. 1242 Mary Dunn Road,West Barnstable,MA•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 C_ Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 1242 Mary Dunn Road Property Address Carol Kirkland Owner Owner's Name ; information is required for every Barnstable MA 02630 4/17/11 page. City/Town State Zip Code Date of Inspection B. Certification (coat.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No El ® Any portion of a cesspool orprivy is within a Zone 1 of a public well. El ® 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 systemmust 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 1:1 ❑ 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. 1242 Mary Dunn Road,west Barnstable,MA•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal.System Form - Not for Voluntary Assessments 1242 Mary Dunn Road Property Address Carol Kirkland Owner Owner's Name information is required for every Barnstable MA 02630 4/17/11 page. Cityfrown 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 ❑ E Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ® Have large volumes of water been introduced to the system recently or as part of 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? i ®' ❑ 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 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)] 1242 Mary Dunn Road,West Barnstable,MA•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1242 Mary Dunn Road Property Address Carol Kirkland Owner Owner's Name information is Barnstable 02630 4/17/11 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design). 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):. 330 gpd per plan on file Number of current residents: 0 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)): Sump pump? ❑ Yes ® No Last date of occupancy: Current Date , 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: Last date of occupancy/use: Date Other(describe): 1242 Mary Dunn Road,West Barnstable,MA•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection -Fora _ Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1242 Mary Dunn Road Property Address Carol Kirkland Owner Owner's Name information is required for every Barnstable MA 02630 4/17/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Board of Health ;. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: 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 inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe):, Approximate age of all components, date installed (if known) and source of information: 1992 - BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No 1242 Mary Dunn Road,West Barnstable,MA-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1242 Mary Dunn Road Property Address Carol Kirkland Owner Owner's Name information is required for every Barnstable MA 02630 4/17/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 2.5 feet Material of construction` El cast iron E 40 PVC El other(explain): Distance from private water supply well or suction line: , feet Comments (on condition of joints, venting, evidence of leakage,-etc.): No evidence of leaks, plumbing properly vented Septic Tank(locate on site plan): Depth below grade: 2.5 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: 5'x 5' x 8' -.1000 gallon Sludge depth: 6 Distance from top of sludge to bottom of outlet tee or baffle 23 Scum thickness 1/2 Distance from top of scum to top of outlet tee or baffle 4 Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Measured 1242 Mary Dunn Road,West Barnstable,MA•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1242 Mary Dunn Road Property Address Carol Kirkland Owner Owner's Name - information is Barnstable MA 02630 4/17/11 .. required for every page. CitylTown 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.): Riser present on tank. Tank in good condition, Inlet tee in good condition, outlet Tee in good condition.. Grease Trap (lo cate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass `❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to.bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet the or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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): 1242 Mary Dunn Road,West Barnstable,MA•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 r— Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 1242 Mary Dunn Road Property Address Carol Kirkland _ Owner Owner's Name information is required for every Barnstable MA 02630 4/17/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm.in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert _D-Box Present 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.): One outlet to leach pit. No evidence of soids carryover. D-box in fair condition and is 4 feet below grade. r' Pump Chamber(locate*on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 1242 Mary Dunn Road,West Barnstable,MA-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 f , Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments , M 1242 Mary Dunn Road. Property Address Carol Kirkland Owner Owner's Name information is required for every Barnstable MA 02630 4/17/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1-6' diam x 6' D with 1' stone ❑ 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.): leach pit has 3' liquid 2' effective depth available per stain line No riser'pi-esent. Leach pit is 4 feet below grade. 1242 Mary Dunn Road,West Barnstable,MA-03/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments acM 1242 Mary Dunn Road Property Address Carol Kirkland Owner Owner's Name information is required for every Barnstable MA 02630 4/17/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ® No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 1242 Mary Dunn Road,West Barnstable,MA•03/08, Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments "w 1242 Mary Dunn Road Property Address Carol Kirkland Owner Owner's Name information atifo is Barnstable MA 02630 4/17/11 required for every --- page. Cityrrown -State Zip-Code Date of Inspection D. System Information cone Y (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where.public water supply enters the building.. to V 0 I Commonwealth of Massachusetts W Title 5 Official (Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 1242 Mary Dunn Road Property Address Carol Kirkland Owner Owner's Name information is required for every Barnstable MA 02630 4/17/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope Z Surface water y ® Check cellar a ❑ Shallow wells Estimated depth to high ground water: fe 1 e per perc log from 1992 et ° 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: ❑ Checked with local excavators, installers - (attach documentation) ❑ 'Accessed USGS database -explain: You must describe how you established the high ground water elevation: Inspector has performed perc tests in the area refer to plan on file at BOH. 1242 Mary Dunn Road,West Barnstable,MA•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 15 P a COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION V TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION ' 8 U 5 Property Address: 1242 Mary Dunn Road sJ Barnstable Owner's Name: Kevin Lennon - Owner's Address: Date of Inspection: l l/1/2002 ov Name of Inspector: (please print) Kevin J. Sullivan Company Name- Ready Rooter TpwHEA� N [P� Mailing Address: P.O.Box 371 Sandwich,MA 02563 MAP- Telephone Number: (508)888-6055 PARCEL : o CERTIFICATION STATEMENT LOT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The System: asses Conditionally Passes Needs Further Evaluation by the Local Authority Fails Inspector's Signature: f Date:_(,11a10Q 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. 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. Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM,INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1242 Mary Dunn Road Barnstable Owner: Kevin Lennon Date of Inspection: l l/l/2002 Inspection Summary:Check A,B,C,D or E./ALWAYS complete all of Section D C. System Passes: 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 stem components as described in the"Conditional P y system P a ass ection need to be replaced or repaired.The system,upon completion of the replacement or repair,as appro ed by the Board of Health,will pass. Answer yes,no or not determined (Y,N,ND)in the for the follo g statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic nk(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank fail a is imminent.System will.pass inspection ifthe existing tank is replaced with a.complying septic tank as approv by the Board of Health. *A metal septic tank will pass inspection if it is structurally so d,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 h.static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or unev distribution box.System will pass inspection if(with approval of Board of Health): broken ipe(s)are replaced obstr tion is removed distr' ution box is leveled or replaced ND explain: The system required pumping m e than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of th oard of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1242 Mary Dunn Road Barnstable Owner: Kevin Lennon Date of Inspection: 11/1/2002 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of ealth 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 cordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will pro t public health,safety and the-environment: _Cesspool or privy is within 50 feet of a surface ater _Cesspool or privy is within 50 feet of a borde ng vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)deter Ines that the system is functioning in a manner that protects the public health,safety and environme . —The system has aseptic tank and soil absorption system(SAS)and the SAS is thin l00 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 o a public water supply. The system has a septic tank and SAS and the SAS is within 50 fee of a private water supply well. _The system has a septic tank and SAS and the SAS is less than 00 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 a DEP certified laboratory,for.coliform bacteria and volatile organic compounds indicates that the we s free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is eq to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must attached to this form. I 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1242 Mary Dunn Road Barnstable Owner: Kevin Lennon Date of Inspection: l l/l/2002 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 logged SAS or cesspool Static liquid level in the distribution box above outlet invert due to and overloaded or clogged SAS or . cesspool — �I iquid depth in cesspool is less than.6"below invert or available volume is less than '/Z day flow _Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _ Z 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. V"Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is 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 supplywell with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] IVO(Yes/No)The system fails. I have determined that one or more of the above criteria exist as described in 310 CMR 15303,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 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 riteria above) yes no the system is within 400 feet of a surface drinkin water supply ' the system is within 200 feet of a tributary to surface drinking water supply — _the system is located in a nitrogen sensiti area(Interim Wellhead Protection Area—IWPA)or a mapped Zone H of a public water supply well If you have answered"yes"to any question ' ection E the system is considered a significant threat,or answered "yes"in Section D above the large system h failed.The owner or operator of any large system considered a significant threat under Section E or fail under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should conta the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B F CHECKLIST Property Address: 1242 Mary Dunn Road Barnstable Owner: Kevin Lennon Date of Inspection: 11/1/2002 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No Pumping information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeks?' =— Has the system received normal flows in the previous two week period?' Have large volumes of water been introduced to the system recently or as part of 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 than 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 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(3)(b)] s Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1242 Mary Dunn Road Barnstable Owner: Kevin Lennon . Date of Inspection: l l/l/2002 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: -D Does residence have a garbage grinder(yes or no): ► � Is laundry on a separate sewage system (yes or no):op[if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no):iVco Water meter readings, if available(last 2 years usage(gpd)): 'off ggo x k Q e .'ZI- ? Sump Pump(yes or no):A2 Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgtt,etc.): Grease trap present(Y or no)es : Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 syst (yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no):Ye s If yes,volume pumped: (o allons--How was quantity pumped determined? Reason for pumping: .e TYPE OF SYSTEM _j,,leptic 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: Were sewage odors detected when arriving at the site(yes or no):ii.,�D Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM,INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1242 Mary Dunn Road Barnstable Owner: Kevin Lennon Date of Inspection: 1l/l/2002 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron V40 PVC_other(explain): Distance from private water supply well or suction line: fi Comments(on condition of joints,venting,evidence of leakage, etc.): SEPTIC TANK: ✓(locate on site plan) Depth below grade: ' " Material of construction:Jl—�Concrete_metal_fiberglass "_polyethylene _other(explain) If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions: -k ct r y; ," Sludge depth: Distance from the top of sludge to bottom of outlet tee or baffle: '' Scum thickness: C" Distance from top of scum to top of outlet tee or baffle: 6- Distance from bottom of scum to bottom of outlet tee or baffle: y 3 " How were dimensions determined: b - Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 14 GREASE TRAP: (locate on site plan) Depth below grade:_ Material of construction:_concrete metal_fiberg s_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet/orbDistance from bottom of scum to bottom obattle: Date of last pumping: Comments(on pumping recommendationlet tee or baffle condition,structural.integrity,liquid levels as related to outlet invert,evidence of lea Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1242 Mary Dunn Road Barnstable Owner: Kevin Lennon Date of Inspection: 11/1/2002 TIGHT or HOLDING TANK: (tank must be pum at time of inspection)(locate on site plan) Depth below grade: Material of construction:_concrete metal rglass_polyethylene_other(explain): Dimensions: Capacity: /ing Design Flow: Alarm present(yes or no): Alarm level: Alarm (yes or no): Date of last pumping:Comments(condition of alars,etc.): DI _/ DISTRIBUTION BOX: 6,� (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: n Comments(not 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: (loca/siten) Pumps in working order(yes or nAlarms in working order(yes or nComments(note condition of pumondition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1242 Mary Dunn Road Barnstable Owner: Kevin Lennon Date of Inspection: 11/1/2002 s SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type aching pits,number: leaching chambers,number. leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): CESSPOOLS: (cesspool must be pumped as'p ection)(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 n Comments(note condition of soil,signs hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: locate on site 1( to plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of draulic failure,level of ponding,condition of vegetation,etc.): I r Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1242 Mary Dunn Road Barnstable Owner: Kevin Lennon Date of Inspection: 11/1/2002 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. Al 10 p ;p U 0 � A\ 3 y I ;� c .S 7 f Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1242 Mary Dunn Road Barnstable Owner: Kevin Lennon rt Date of Inspection: 11/1/2002 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water<\ feet Please indicate(check)all methods used to determine the high ground water elevation: _XZ'bbtained from system design plans on record—If checked, date of design plan reviewed: S— Observed site(abutting property/observation hole within 150 feet of SAS) Checked with the 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: ,/�/G� 5`at d� f �.ra\�.r i ��- <�n•v� \.1\ ��.l..4.t— C TOWN OF BARNSTABLE LOCATION f T a2 14,41`t**' D U vA' k2) SEWAGE# VILLAGE, e (/ 1,Y4 A Q U z-,) ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 400 LEACHING FACILITY: (type) (size) /G O G e-,01.4 NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facilityµ Feet Private Water Supply Well and Leaching Facility (If any wells exist . on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leac ' acili ) Feet Furnished by L_ r nn Ui - C o o I . N THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEAL.T = tom.. . . : ................................. ..� AvorFatiun for Disposal Works Tonmra . Application is hereby made for a Permit to Construct or Repair an Individual Sewage' Disposal PP Y CDC) P ( ) g P System at: ........ ...... .. _....... ---- -----____----•-------------------------------- L ti f)ddress6 � j ��o'r I.ot :�o. •...1_...... .... //9 lf..G.�yCj------"--------•----------------------•-- ........-`_12, �_w�.!�!..-- '�r�... W caner ,7iy� 9Address Installer Address �� _S� Type of Building Size Lot...... _....��.. q. feet Dwelling—No. of Bedrooms ._.___. ______________"_-"-.___-__•"Expansion Attic ( ) Garbage Grinder (Al0 '� Other—T e of Building No. of persons............................ Showers — Cafeteria a YP g --- �-� P ( ) ( ) Other W fi ......... . -/------------------- ----------- • ----•-- Design Flow............... � ."._._gallons per pq d� Total daily flow____._._.__.3�- 0-i... }' Y• !! --------------gallons. WSeptic Tank—Liquid capacity/000gallons Length........ Width--- Diameter..__............ Depth................ x Disposal Trench—No..................... Width......... Total Length..................... Total leaching area....................sq. ft. Seepage Pit No.......I............ Diameter....___lj_. .... Depth below inlet... ........... Total leaching area_f4.?._..sq. ft. Z Other Distribution box ( ) Dosing t k �� ~' Percolation Test Results Performed by.... - : ! �P e "T' Date. . ,.a Test Pit No. 1..... _-____minutes per inch Depth of Test Pit.__ !S6._..___ Depth to ground water___ � �' _.__. rZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.----------------------- ------------ O Description of Soil Qo -^�"' r �`v `l m � vitie . Ge�•tG�_^: >- a� lie........ w •-•---------------------------------------"----------------------------"-----------"--"-""-------"--------•---"--------------------""""------------"-"---"--"""-""-"""------------•----•-••-•---•...... U Nature of Repairs or Alterations—Answer when applicable_____________________________"-_-__-----_-.--_--_-"_______--_.-___-_--------__"-_-_-_--•----_-. "-•••---•---•---------------•---.__•••••••--•••--•--•---•-••--••••••-•--•••----•---..........___._._....._.._...•----•------••••----....._..._..-•-----•- .............-................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of u:LE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be i the board of health. Signed. .._ ....... ............ ............. ..........................�� D to Application Approved 133f : -"".......-- - ----- .................... ""---- -- �•1�'� Date Application Disapproved for the following reasons:................................................................................................................ -•........................................................................................................-•••._..___._.._._.---•..._.••....-••-•...........---••--••••-•-•--•--• ....................... �j Date Permit No....7_._��__._....f_1 - ------------- Issued._____ "_l" — . Date No..- •,;= ->� ' FR$...1/,r .ram THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH ................. . 1............_OF..... Allp iratinn for Uispniittl Workii Tonstrnrtion rrtni# Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal System at F Lo t. ddress ` ? or Lot No ........... ... r ............................. ............."r?.... ftl e i �Qaner r`�• �!". 9 Address w _-. a- --,- . €'... ... ------ -•--------------------- .............. ....... .- --............ rf Installer Address d Type of Building Size Lot...........................Sq. feet Dwelling—No. of Bedrooms ............................. Attic ( ) Garbage Grinder (Vo aOther—Type of Building ` f. k. No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixt e ----....--•--••-•••-•••--••--••--•-••---•--------•-•---•-••---•---••-----•••••-•--•.....---•-••--------•- Design Flow.----••--•••--•== -----g P W • 4 allons er,pon e day. Total daily �iow.._..... ...................gallons. Iff Ri Septic Tank—Liquid capacity/VA1 _gallons Length-_____. ?__._ Width.- Diameter__ _y.f..... Depth................ Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No......I............. Diameter.._.._.+`. *._.__.. Depth below inlet__.,/2__:.._....... Total leaching area. f'n-._'..___sq. ft. z Other Distribution box ( ) Dosing t Percolation Test Results Performed by_ �` _ - ...___ ........ . ...... Date... �,f/�'�'T°_�_..._._.... as Test Pit No. 1-----` L....._.minutes per inch Depth of Test Pit..f. i.6_-...... Depth to ground water.._��'_A1" (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ --------- ................................. f .._... ... ' rO Description of Soil � � ... . .. 7 .................. � r___. .... ......-xf- 4 --- `Y ..................................fi, � W UNature of Repairs or Alterations—Answer when applicable............................................................................................... ----------------------------------•----•----................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'TILE i of the State'Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has ber{i idly the board of health. ( 1- try / F ,v - �' Signed--• _._ _�! ...... .......... .................... .......le................ 57Date Application Approved Byy,,, Alp. C? �y+ ,-' �' ..-- . •......................... ....... �(.-.---' �..-� )ate •° �^�• Application Disapproved for the following reasons---------- -------- ---------------------------•-----------------------------------•••--........_ -----------•--••-••----•--------•----•••---•.....---•.............•---•--•...•-•-•------••...--•-----•-••........................................••••----•------•---••........•-•---. ••--....------ Date Permit No----9 _ - __.._.. Issued.... 1 THE COMMONWEALTH OF MASSACHUSETTS � f_ BOARD OF HEALTH . .. f�'.............. �.f� ...o .......OF....../....f sl... .�......................................... t. Qrr#if iratr of TOutpliattrr THi -IS ,B0 CE TIFY That the Individ al_,Sewage Disp sal System constructed (,X4) or Repaired ( ) at _ __._.._..._e._.___. _/fF�c/__ '_' '__A'^.............................................. has `Mi3�/1.6"'. 1..) .......................................................... has been installed in accordance with the provisions of TITI.E5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No. . /_ _• _ _ ____ dated-----,_�j-_._.___ _.-_- THE ISSUANCE OF THIS CERTIFICATE SHA11C& BE C ?*STRUE® AS A G>rIARAN TIiAT HE. SYSTEM WILL FUNCTION SSFACTORY. DATE._. o •.._..��_.Z....._Lee......Y/.��• Inspector.-•�--� ---------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .. F'Le......OF...... {� ............ l...... ........ N FEE... Dispos-4 Works Tvn#rut WPM ri _ ...�� Permission is hereby granted----•-,-- '.............................................................--....----•---• ------ /LGI'��---•--..................... . _ to Construct (N) or Repair ( )n an Individual Sewage Dis oral Systn atNo... _f> ° . �, 4 A......................................hf} 'Pj r 1l------•-------•---••----------------------------•---•-•--•--••-......_... Sweet as shown on the application for Disposal Works Construction Permit o _- ated..... „� ..... ._. ..-•-•••--••••..... �3 -... . ---•---.................................... DATE. � ................... Board of Health FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS T 7. 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