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HomeMy WebLinkAbout0244 MIDPINE RD - Health 244 Midpine Road Barnstable P A 355 005 I f a o c p � 9 A Commonwealth of Massachusetts Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments, wM 244 Midpine Road Property Address Natalie Galvin Owner Owner's Name information is Barnstable Cumma uid MA 02637 June 2,.2013 required for every ( 4 ) 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 filling out forms A. General Information on the computer, use only the tab 1. Inspector: f Y key to move your cursor-do not David D. Flaherty Jr., IRS, REHS use the return Name of Inspector key. Flaherty Environmental Services IC=V Company Name P.O. Box 81 Company Address ITV Yarmouth Port MA 02675 City/Town State. Zip Code 508-362-1657 SI#4713 Telephone Number License Number B. Certification I certify that l 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 0 Fails. Needs•Further Evaluation by the Local Approving Authority ' June 3,2013 Insp ors 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 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DER The origina(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. (PAS D t5ins•3113 Title 5 Official Inspection Forth: rtace Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w, 244 Midpine Road Property Address Natalie Galvin Owner Owner's Name information is required for every Barnstable (Cummaquid) MA 02637 June 2, 2013 page. Cityrrown 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..lf"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•3113 Title 5 official Inspection Forth:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts v Title 5 Official '!nspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments, M 244 Midpine Road Property Address Natalie Galvin Owner Owners Name information is Barnstable umma uid required for every ( q ) MA 02637 June 2, 2013 page. Cityrrown 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 (cont.): ❑ Observation of sewage backup or breakout 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): ❑ 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: El 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-3/13 Title 5 Official Inspection Forth: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- °�M ,•''� 244 Midpine Road Property Address Natalie Galvin Owner Owner's Name information is bl t Barnsae Cumma uid MA 02637 June 2, 2013 required for every ( q ) page. Cityrrown 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. ❑ 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 ttie 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 El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 244 Midpine Road Property Address Natalie Galvin Owner Owner's Name information is required for every ( q ) Barnstable Cumma MA 02637 June 2, 20153 page. Cityrrown uid State Zip Code Date of Inspection B. Certification (cont.) 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 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 toaa surface water supply. ED ® 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 CM 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. 1 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 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- °w 244 Midpine Road Property Address Natalie Galvin Owner Owner's Name information is )q�required for every Barnstable Cumma uid MA 02637 June 2, 2013 page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided„by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of 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 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): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts` f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 244 Midpine Road Property Address Natalie Galvin Owner Owner's Name information is bl t arnsae (Cumma uid required for every B q ) MA 02637 June 2, 2013 page. City/Town State Zip Code .Date of Inspection D. System Information Description: Number of current residents: 0 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 Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): '11: 332 gpd; 12:321 gpd Detail: extensive irrigation system 1 Sump pump? ❑ Yes ® No _ Last date of occupancy: 2013late 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•3113 Title 5 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', . 244 Midpine Road H Property Address Natalie Galvin Owner Owner's Name information is � q required for every Barnstable Cumma uid) MA 02637 June 2, 2413 page. City/Town 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, last year° Was system pumped as part of the inspection? ❑ Yes ®r No If yes, volume pumped: gallons How was quantity'pumped determined? Reason for pumping: Type of System: ® 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): t5ins•3113 ° Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 244 Midpine Road Property Address Natalie Galvin Owner Owner's Name information is required for every Barnstable ( q )Cumma uid MA - 02637 June 2, 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:- Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: 3.5feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >50feet Comments(on condition of joints, venting, evidence of leakage, etc.): joints tight, venting through dwelling adequate, no evidence of leakage. Septic Tank(locate on site plan): Depth below grade: 2.5feet 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: 1000 gallon Sludge depth: 4" t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 244 Midpine Road Property Address Natalie Galvin Owner Owner's Name information is Barnstable Cumma required for every ( quid) � MA 02637 June 2;2013 page. City/Town 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 3011 Scum thickness Distance from top of scum to top of outlet tee or baffle 71' . s Distance from bottom of scum to bottom of outlet tee or baffle . 13' How were dimensions determined? sludge judge, tape measure Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): maintenance pumping not necessary at this time but should be performed every two to three years, inlet&outlet tees good, tank seems structurally sound, liquid level appropriate, no evidence of leakage Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness w , f 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 5 Official fnspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal.System Form-Not for Voluntary Assessments 244 Midpine Road Property Address Natalie Galvin Owner Owner's Name information is . Barnstab le (Cumma uid required for every q ) MA 02637 June 2, 2013 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.): 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 f 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments w ,•'' 244 Midpine Road Property Address Natalie Galvin Owner Owner's Name information is bl t Barnsae(Cumma uid MA 02637 June 2, 2013 required for every q ) ' 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 011 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.): dbox seems level, no evidence of leakage 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 Forth:Subsurface Sewage Disposal System•Page 12 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 244 Midpine Road Property Address Natalie Galvin Owner Owner's Name information is C bl t Barnsae umma uid required for every � q ) MA 02637 June 2, 2013 page. City/Town State Zip Code. Date of Inspection D. System Information (cont.) Type: ® leaching pits number: (1)6'x6'w/stone ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: r` ❑ 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.): (1)6'x 6' leach pit with 2' stone around, soils sandy &gravelly, no signs of breakout or hydraulic. failure, stain line 3.5' below inlet invert, vegetation typical (lawn) 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 I • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 244 Midpine Road Property Address Natalie Galvin Owner Owner's Name information is Barnstable Cumma uid MA 02637 June 2, 2013 required for every ( 4 ) page. C4rrown 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.): 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•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 17 r Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 244 Midpine Road Property Address F Natalie Galvin Owner Owner's Name ri information is required for every Barnstable (Cummaguid) MA 02637 June 2, 2013 ' page. City/Town State Zip Code Date of Inspection D. System Information (cost.) 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 N K.� U I WA, t5ins•3113 Tr',e 5 G=_saw�r Form:Su._-_ftne Szsrex D.sp System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 244 Midpine Road Property Address Natalie Galvin Owner Owner's Name information is Barnstable (Cummaguid MA 02637 June 2, 2013 required for every. ) ' page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells >25 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: pate ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS maps and Town of barnstable's Hydrogeologic Map shows groundwater contours at 25' below grade. Before filing this Inspection Report, please see Report Completeness Checklist onInext page. . t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 r i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M ,•'' 244 Midpine Road Property Address Natalie Galvin Owner Owner's Name information is required for every Barnstable (Cummaguid) MA 02637 June 2, 2013 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist. ® 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 t t5ins-3/13 Title 5 Official Inspection Foos:Subsurface Sewage Disposal System-Page 17 of 17 COMMONWEALTH OF 1t ASSACHUSIETTS ExEc=-E OFFICE OF EN`TIRONMEN-TAL AFFAI DEPARTMENT OF ENVIRONMENTAL RO MO-TIO-J WIAP A �5 PARCEL ,?.� NOV 3 2004 G0-r u TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: oZ y i Owner's Name- Owner's Address: a 6�7 Date of Inspection• 11 Name of Inspector:(plea a print 2 e[/ei T Company Name: p -{ Mailing Address: ��s/�ecr tubs /4 0.?6 eq Telephone Number: S4 SS--7-ft-'Oa 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 15.340 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:tQ /o vy 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 pow the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15t2000 page I Page 2 of 11 s. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE WSPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: yy cal' Owner. 6 ysn&4 Date of luspection• Z0j9tD f Inspection Summary: Check AAC,D or E/ALWAYS complete all of Section D A. System Passes: f� I have not found any information which indicates that any of the failure criteria described in 310 CUR 15.303 or in 310 CUR 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"secti to be replaced or repaired.The system,upon completion of the replacement or repair,as approved b Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the folio ' g statements.If`not determined"please explain. The septic tank is metal and over 20 years old' or septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration failure is imminent.System will pass inspection if the . existing tank is replaced with a complying septic approved by the Board of Health. *A metal septic tank will pass inspection if it is y sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old' available. ND explain: Observation of sewage backu or beak out or liigh static water level in the distribution box due to broken or obstructed pipe(s)or due to a bro settled or uneven distribution lox.System will pass inspection if(with approval of Board of Health): broken pipes)we obstrucdon isramoved distriNdim box is knueled Of replaced ND explain: The syste pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection (wiih approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: ;2 4K t 0j 2 v Owner: Gf$SQN Date of Inspection: to r g(oy C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in or to determine if the system is failing to protect public health,safety or the environment I 1. System will pass unless Board of Health determines in accordance ith 310 CMR 15.303(l)(b)that the system is not functioning in a manner which will protect public ealth,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 veg ted wetland or a salt marsh 2. Svstem will fail unless the Board of Healt and Public Water Supplier,if any)determines that the system is functioning in a manner that prat the public health,safety and environment: _ The system has a septic tank and it absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to surface water supply. _ The system has a septic and SAS and the SAS is within a Zone I of a public water supply. _ The system has a sep * tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a tic tank and SAS and the SAS is Iess than 100 feet but 50 feet or more from a private water supply ell".Method used to determine distance •*This system p if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and vo file organic compounds indicates that the well is free from pollution from that facility and the presence ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure crite a are triggered.A copy of the analysis must be attached to this form. 3. Oth 3 Page 4 of I l OFFICIAL INSPECTION FORM—NOT-FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISMAL SYSTEM INSPECTION FORM PARTA- CERTIFICATION{continued) Property Address: Owner: Date of inspection: V D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each ofthe following for aIl 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 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 coMmu bacteria and volatile organic compamuls 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 CUR 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 mast serve a fa a design flow of 10,000 gpd to 15,000 gpd- You must indicate either"yes"or"no"to eich of the foll g: (The following criteria apply to large systems in to the criteria above) yes no — ` the system is within 400 feet of ce drinking water supply the system is within.200 f of 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 ve the large system has failed The owner or operator of any large system considered a. significant threat der Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The em owner should contact the appropriate regional office of the Department. 4 J Page 5 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST . Property Address: Owner. c ,�, Date of Inspe on- C� --- 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? _ C 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? . p� 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? _y _ 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 Existing information.For example,a plan at the Board of Health. OL — Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CNM 15.302(3)(b)] 5 Page 6 of I 1 OFFICIAL JNSPECTI®N FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: . �! t Owner: Date of Insp on• U O-r FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): S Number of bedrooms(actual): 3. DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): sr Number of current residents: Does residence have a garbage grinder(yes or no):�o Is laundry on a separate sewage system(yes or no): AW (if yes separate inspection required) Laundry system inspected(yes or no): AV Seasonal use:(yes or no): Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): AV Last date of occupancy: ! v COMMERCIAIANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.20T and Basis of design flow(seats/pers $,etc.): Grease trap present(yes or no):i Industrial waste holding resent(yes or no): Non-sanitary waste disch ged to the Title 5 system(yes or no):— Water meter readings,' available: East date of occup y/use: OTHER( e): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): AoO 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) Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: O . S Were sewage odors detected when arriving at the site(yes or no): ltX7 6 Page 7 of I I OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: oZ y I` w Owner- Date of Inspec ion: oq BUILDING SEWER(locate on site plan) . s� Depth below grade: c�y Materials of construction:_cast iron A4,40 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: Material of construction: concrete metal fibe glass_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: Lam! Sludge depth: 3' -- Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: I y r Distance from top of scum to top of outlet tee or baffle: _ M Distance from bottom of scum to bottom f outlet tee or affle: l How were dimensions determined:M eas uretX Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid Ievels as related to outlet inert,evidence of o ,etc.): —900WIV ` �/ 1 r GREASE TRAP:_(locate on site plan) Depth below grade: Material of construction: concrete me _fiberglass_polyethylene,other (explain): Dimensions: Scum thickness: Distance from top of scum to to f outlet tee or baffle: Distance from bottom of se bottom of outlet tee or baffle: Date of last pumping: Comments(on pumpin ommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet inv evidence of leakage,etc.): ---------------------------------------- r Page s of i 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1r vftow Owner: Gar s&t f Date of InspeAion: PC>1810cf TIGHT or BOLDING TANK: (tankZmustbe at time of inspectionxlocate on site plan) Depth below grade:Material of construction: concrete fiberglass_polyethylene other(explain): Dimensions: Capacity: Vno): allons Design Flow: allonslday Alarm present(Alarm level: worldng order(yes or no): Date of last pumComments(connd float switches,etc.): DISTRIBUTION BOX: I( (if present must be opened)(l0cate on site plan) Depth of liquid level above outlet invert: C'1/_al Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage iV o or out of box,etc.): (L 7 i ZtC box cv�.s t2 dc. a c�t� t�l tY'i� Kr, S k 0r� 5_:4 L o VO . PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no):. Alarms in working order(yes or Comments(note condition o ump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner:Date of Inspe ion•_ LD $ o/ I i SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SA S S not located explain why: Type leaching pits,number- leaching chambers,number. leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Typetname of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): �C.ts ct . X � ��sdrrov +►� b d �a o 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' ow(yes or no): Comments(note condi ' n 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 1,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 3 a PART C SYSTEM INFORMATION(continued) Property Address- s` --�,�u � t/Ilr c dl a Owner.G',V's M Date of Inspection: LO 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. rAl 4-0 VU V" eAf f.r r S 3-6 I • Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address- 7 ` Owner: Date of Inspect ion-.-r-1-d(qta5� .— SITE EXAM Slope �,'eS Surface water &JO Check cellar`ea. Shallow wells tLb Estimated depth to ground water aR�_ 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 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 gr and water elevation: ITS l iAA�—66k,t K 0cev. e & 0,j 11 oa SS TROY WILLIAMS L 13� SEPTIC INSPECTIONS Certified by MA Department of Environmental Protection (508) 38 -1300 19 Hummel Drive South Dennis, A 02660 L . COMMONWEALTH OF MASSACHUSE'I"I'S EXECUTIVE OFFICE OF ENVIRONMENTAL,AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION PropertN Address: 244 Mid Pine Road Cummaquid,MA Owner's Name: Frederick Brown Owner's Addres,,: 244 Mid Pine Road Yarmouthport,MA 02675 v Date of Inspection: April 3, 2001 O Name of Inspector: 1'roy M. Williams Company Name: Troy Williams Septic Inspections Mailing Address: Z. e 19 Hummel Drive Telephone Number: South Dennis,MA 02660 (508)385-1300 ]my CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address aed below is true,accurate and complete as of the time of the inspection. The inspection n training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The systcnr Passes Conditionall\ Passes Needs l urther Evaluation by the Local Approving Authority Fails Inspector's Signature: Z,J;,,(, ,� Date: //y/off The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of I lealth 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 Although system meets the minimum requirements set forth by the Massachusetts Department of Environmental Protection,certification is not to be construed as a guarantee of future working condition of system,piping or components. This inspection represents the conditions of the system on the Date of Inspection noted above. ""This report only describes conditions at the time of inspection and under the conditions of use at that time. T his 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 paee I Page 2 of 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A . CERTIFICATION (continued) 244 Mid Pine Road Property Address: Cummaquid,MA Frederick Brown Owner: April 3, 2001 Date of Inspection: 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 CNIR 13.303 or in 3 1 U CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: kt//; 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 indicatine 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($)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 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 244 Mid Pine Road Cummaquid,MA Owner: Frederick Brown Date of fnspection: April 3,2001 C. Further Evaluation is Required by the Board of Health: A,//4 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 Hill 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 I of a public water supply. _ The system has aseptic 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 front 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 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) 244 Mid Pine Road Property Address: Cummaquid,MA Frederick Brown Owner: April 3, 2001 Date of Inspection: 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. N/q Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. NIA Any portion of a cesspool or privy is within a Zone l of a public well. _ HI-i Any portion of a cesspool or privy is within 50 feet of a private water supply well. / g 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 %%ater 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.) N,o (Yes/No)The system fails. 1 have determined that one or more of the above failure criteria exist as descrihed 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: N119 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 11 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 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 244 Mid Fine Road Cummaquid,MA Owner: Frederick Brown Date of Inspection: April 3, 2001 Check if the following have been done. You must indicate"yes"or"no"as to each of the followine: Yes No information was provided by the owner. occupant, or Board of I lealth _ 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 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 _ 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)] ti 5 f Page 6 of 1 1. OFFICIAL INSPECTION FORM -.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 244 Mid Pine Road Cummaquid,MA Owner: Frederick Brown Date of inspection: April 3, 2001 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 + prIV DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 33c, Number of current residents: d Does residence have a garbage grinder(yes or no): Y6 j Is laundn on a separate sewage system (yes or no): Al— [if yes separate inspection required] Laundry system inspected(yes or no):' w/A Seasonal use: (yes or no): Ivo Water meter readings, if available(last 2 years usage(gpd)): 60 _ j o,2.,o,,� Sump pump(yes or no): Last date of occupancy: _Oc_,,P):,J. COMMERCIAL/INDUSTRIAL n,//9 Type of establishment: Design flow(based on 310 CMR 15.203): gpd 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): GENERAL INFORMATION Pumping Records Source of information:22�/l/,i./� f li/r/y_�2/s'/sz� ioj��/f�, Was system pumped as pan of the inspection(yes or no): ,/J 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) _Tight tank _Attach a copy of the DEP approval Other(describe):. Approximate age of all 1components. date installed(if known)and source of information: �]r y NK I Yl(j y ✓ I C C.�,p� % Y 201. f G Were sewage odors detected when arriving at the site(yes or no): ivo 6 Page 7 of I I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 244 Mid Pine Road Cuntmaquid,MA Owner: Frederick Brown Date of Inspection: April 3,2001 BUILDING SEWER(locate on site plan) Depth belo�k grade: Materials of construction: cast iron _40 PVC /other(explain): 6 T^sue. Dktanc:> front prig ate water supply well or suction line: ;v/,q Comments(on condition of joint's, venting,evidence of leakage, etc.): J /V S 1,t .af 1 h f c w c1 4 v.>1 . �t 4,✓ N T �1, � 'h Yh� G i� / N )IIO•G V'h 1. SEPTIC TANK: ✓(locate on site plan) Depth below grade: 19" > > r:J. A w•+� - !'. Material of construction: 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: S'-A q )C e ^ /000 Sludge depth: 3 Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: —ri,;„ Ic-7 ,. Distance from top of scum to top of outlet tee or baffle: G Distance from bottom of scum to bottom of outlet tee or baffle: /4/ How were dimensions determined: P"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.): L a /�IU t.✓ ..*9! t/� 9.w._ U t J/�C- YH 6L�✓.t. L'�G� C •/N �!/��"' Cr�bl_S hO GREASE TRAP:2A(locate on site plan) Depth below grade: 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: 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 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 244 Mid Pine Road Cummaquid,MA Owner: Frederick Brown Date of Inspection: April 3, 2001 TIGHT or HOLDING TANK:/vim(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 Flo��: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: 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 carrygver, any evidence of leakage into or out of box,etc.): 19-13 e('j'­ � Ty -.) -, o r!1• U ✓fir✓ w � Q ��° tJ �w.s' L t . PUMP CHAMBER:&14(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 1 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 244 Mid Pine Road Cummaquid,MA Owner: Frederick Brown Date of Inspection: April 3, 2601 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located explain wh). Type leaching pits,number: I ' ►' l •��(, /Q l w: 2 `r by h 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.): Lc., .2 - ./ -c._ S r-..c_ C.� - / i6.. ww4 �tdvj. /lo ev. G��. � � � c.L' �j, ✓ K.. (.� 1 s , ., S t- �... }''} S � W 4V-�- -T�✓ J- r y-<.1 CESSPOOLS: AVj(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 or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: A1 f) (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) 244 Mid Pine Road Property Address: Cummaquid,MA Frederick Brown Owner: April 3, 2001 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, V I-C-y I .28' zs y6 ' L p;r wfl 2'S�iN�-- 10 Page 1 I of I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 244 Mid Pine Road Cummaquid,MA Owner: Frederick Brown Date of Inspection: April 3, 2001 SITE EXAM ✓ Slope Surface water Check cellar Shallow wells Estimated depth to groundwater 20+ feet Adjusted high ground water elevation feet Please indicate(check)all methods used to determine the high ground eater elevation: Obtained from system design plans on record-if checked,date of design plan reviewed: ✓ Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: 1„fie,�•,c Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describehow you established the high ground water elevation: I s e s 1, 2'V f r 11