HomeMy WebLinkAbout0286 MIDPINE RD - Health >R
86 Mid Pine Road
►:
Bamstable
349-024
oay
Commonwealth of Massachusetts
OW Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
286 Midpine Road, Barnstable, MA
Property Address
Elizabeth C Constantino, P. O. Box 54, Cummaquid, MA 02637
Owner Owner's Name /
information is Barnstable V MA 02630 12/04/2020
required for every
page. Citylrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information j a.
on the computer,
use only'the tab Reid C. Ellis
key to move your Name of Inspector
cursor-do not Ellis Brothers Const. Co.
use the return Company Name
key.
23 Enterprises Road, P. O. Box 59
� 16 Company Address
Yarmouth Port MA 02675
City/Town State Zip Code
508-362-6237 S12189
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 16.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above;the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and main nance of on-site sewage disposal systems.After conducting this inspection I have determined
that the ystem:
1. Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
r 1 '
Inspect s Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system 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 form should be sent to the system.owner and copies sent to
the buyer, if applicable,and the approving authority.
Please note: 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.
t5insp.doc-rev.7126=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
286 Midpine Road, Barnstable, MA
Property Address
Elizabeth C Constantino, P. O. Box 54, Cummaquid, MA 02637
Owner
Owner's Name
information is Barnstable MA 02630 12/04/2020
required for every
page. CityrFown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and.all.of 4 and 6.
1) System Passes:
/`� I have not fourinformation 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:
I
2) System Conditionally Passes:
❑ One or more system components E s described in the"Conditional Pass"section need to be
replaced or repaired. The system, i ipon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes', "no"or"not de ermined"(Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 y ars old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltratior or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replac d with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspectic n if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is I ss than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
286 Midpine Road, Barnstable, MA
Property Address
Elizabeth C Constantino, P. O. Box 54, Cummaquid, MA 02637
Owner Owners Name
information is Barnstable MA 02630 12/04/2020
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.): jT�
❑ Pump Chamber pumps/alarms not operatio ial. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break ou or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a roken, settled or uneven distribution box. System will
pass inspection if(with approval of Board o Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below
❑ distribution box is leveled or replac d ❑ 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 approv I of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
3) 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 I iealth, safety or the environment.
a. System will pass unless Board f Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not i unctioning in a manner which will protect public health,
safety and the environment:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Forth.Subsurface Sewage Disposal System-Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
286 Midpine Road, Barnstable, MA
Property Address
Owner
Elizabeth C Constantino, P. O. Box 54, Cummaquid, MA 02637
Owner's Name
information is Barnstable required for every MA 02630 12/04/202
page. City/Town State -Zip Code
P Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of H alth (and Public Water Supplier, if any)
determines that the system is functionin in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil a sorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributa to a surface water supply.
❑ The system has a septic tank and SAS nd the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS nd the SAS is within 50 feet of a private water
supply well.
F
El The system has a septic tank and SAS nd 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 pres ce of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other fail re criteria are triggered. A copy of the analysis must
be attached to this form.
C. Other:
I
I
4) 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
clogged SAS or cesspool p to overloaded or
❑ Discharge or ponding of effluent to the surface of the ground or surface waters t
due to an overloaded or clogged SAS or cesspool &`
t5insp.doc-rev.712WO18 s
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 :
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
286 Midpine Road, Barnstable, MA
Property Address
Elizabeth C Constantino, P. O. Box 54, Cummaquid, MA 02637
Owner Owner's Name
information is Barnstable
required for every MA 02630 12/04/2020
page. City/Town State Zip Code Date of inspection-
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cunt.)
Yes No
❑ 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
tributary to a surface water supply. water supply or
Eli] Any portion of a cesspool or privy is within a Zone 1 of a public water supply
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. [Phis
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 2000 gpd-
10,000 gpd.
❑ 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.
, � )5 Large
Systems: To be considered a large systen i the system must serve a.facilit with a
design flow of 10,000 gpd to 15,000 gpd. y
For large systems, you must indicate either"yes"or'no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet o a surface drinking water supply
El the system is within 200 feet o a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitro en sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zo a II of a public water supply well I
t5insp.doc-rev.7l26/2018
Tille 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
286 Midpine Road, Barnstable, MA
Property Address
Elizabeth C Constantino, P. O. Box 54, Cummaquid, MA 02637
Owner Owners Name
information is Barnstable
required for every MA 02630 12/04/2020
page. City/Town
State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.ft
6. You must indicate "yes" or"no"for each of the following for aH inspections:
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)
V ❑ Was the facility or dwelling inspected for signs of sewage back up?
/ ❑ Was the site inspected for signs of break out?
VElWere all system components,elccluding the SAS, located on site?
EI 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)]
tSinsp.doc-rev.7262076 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
286 Midpine Road, Barnstable, MA
Property Address
Elizabeth C Constantino, P. O. Box 54, Cummaquid, MA 02637
Owner Owner's Name
information is Barnstablerequired for every MA 02630 12/04/2020
page. City/Town State zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms n desi : r
( 9 ) Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):O
Description: r
•��i/%�'Y!/" - _ Vie//'�V
V.
E
Number of current residents:
Does residence have a garbage grinder?
❑ Yes
Does residence have a water treatment unit? ❑ Yes No
If yes, discharges to:
Is laundry on a separate sewage system?(Include laundry system inspection
information in this report.) ❑ Yes N
Laundry system inspected?
❑ Yes N
Seasonal use? ❑ Yes No
Water meter readings, if available (last 2 years usage(gpd)):
Detail* � �
i A5 r
�71��s-A—
0;K14,,
Sump pump?
❑ Yes No
Last date of occupancy: - —` .fZ—_"-/'—gv
Date
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Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�.. 286 Midpine Road, Barnstable, MA
Property Address
Elizabeth C Constantino, P. O. Box 54, Cummaquid, MA 02637
Owner Owner's Name
information is Barnstablerequired for every MA 02630 12/04/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/industrial Flow Conditions: J'O�
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
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to: f
Industrial waste holding tank present? El Yes ❑ No
Non-sanitary waste discharged to the Title 5 syste ?• ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use:
Date
Other(describe below):
g
(
3. Pumping Records:
Source of information: �Jhl�' '.�,
Was system pumped as part of the inspection? IJ Yes ❑ No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:.
t5insp.doc•rev.726/2018 1
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 1
f
t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
s
y� 286 Midpine Road, Barnstable, MA
Property Address
Elizabeth C Constantino, P. O. Box 54, Cummaquid, MA 02637
Owner Owner's Name
information is Barnstable MA 02630 12/04/2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of stem:
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 1/A system by system operator under contract
❑ Tight tank.Attach a copy of the DER 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 R<O
5. Building Sewer(locate on site plan):
Depth below grade:
feet
Material of constructiW40
❑cast iron PVC ❑other(explain):
/�Distance from private water supply well or suction line: G� ' feet
Comments(on condition of joints, venting, evidence of leakagee etc.):
!J W /We— Ali'
10
t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
286 Midpine Road, Barnstable, MA
Property Address
Elizabeth C Constantino, P. O. Box 54, Cummaquid, MA 02637
Owner Owner's Name
information is required for every Barnstable MA 02630 12/04/2020
page. CityfTown State Zip Code Date of Inspection
D. System Information (coat.)
6. Septic Tank(locate on site plan):
Depth below grade:
feet
Mate ' I of construction:
concrete ❑ metal ❑fiberglass ❑ polyethylene
❑ other(explain)
�L
/ [Is
nk is:eta ist a-e:
/9 years
ge comed by a Certificate of Compliance? (attach a copy of ce dicate) ❑ Yes ❑ No
Dimensions:
Sludge depth: (S
N, -
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?
Comments(on pumping recommendations, inlet and outlet tee or' ffl n, structural integrity,
liquid levels as related to outlet invert, ev d ce o leakage, etc.):
� ld ��
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
fw
Commonwealth of Massachusetts
Title 5 Official Inspection Form
j Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
286 Midpine Road, Barnstable, MA
Property Address
Elizabeth C Constantino, P. O. Box 54, Cummaquid, MA 02637
Owner Owner's Name
information is Barnstable' MA 02630 12/04/2020
required for every
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.) A/
7. Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fib rglass ❑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 OUtlE t tee,or baffle
Date of last pumping: Date
Comments(on pumping recommendations, inle and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumpe 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
t `
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
286 Midpine Road, Barnstable, MA
Pr operty Address
Elizabeth C Constantino, P. O. Box 54, Cummaquid,MA 02637
Owner Owner's Name
information is Barnstable
required for every MA 02630 12/04/2020
page. City/Town
State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.) ✓V
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes
❑ No
Date of last pumping:
Date
Comments(condition of alarm and float switch s, etc.):
t
*Attach copy of current pumping contract(re uired). Is copy attached?
❑ Yes ❑ No
9. Distribution Box(if present must be opened)) (locate on siteplan):
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.):
t
A
t5insp.doc-rev.7/26/2018
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
f:
r:
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I
e Disposal System Form -Not for Voluntary Subsurface Sewage sp y Assessments
F
y 286 Midpine Road, Barnstable, MA
Property Address
Elizabeth C Constantino, P. O. Box 54, Cummaquid, MA 02637
Owner Owner's Name
information is Barnstable MA 02630 12/04/2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
10. Pump Chamber(locate on site plan): /�o
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, ystem is a_conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS 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
Type/name of technology:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
286 Midpine Road, Barnstable, MA
Property Address
Elizabeth C Constantino, P. 0. Box 54, Cummaquid, MA 02637
Owner Owner's Name
information is Barnstable MA 02630 12/04/2020
required for every
page. CityrTo`^n State Zip Code Date of Inspection
D. System Information (coat.)
11. Soil Absorption System(SAS) (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.): =
�Vw
`;9 44A&- ZJ WJ:��
�
c
12. Cesspools (cesspool mu pumped as art of ingpection) (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 I iydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
Commonwealth of Massachusetts
j - Title 5 Official Inspection Form
'Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
286 Midpine Road, Barnstable, MA
Property Address
Elizabeth C Constantino, P. O. Box 54, Cummaquid, MA 02637
Owner Owner's Name
information is Barnstable
required for every MA 02630 12/04/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan): 01
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraul failure, level of ponding, condition of vegetation,
etc.):
f I
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
c� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
286 Midpine Road, Barnstable, MA
Property Address
Elizabeth C Constantino, P. O. Box 54, Cummaquid, MA 02637
Owner Owner's Name
information is Barnstable MA 02630 12/04/2.020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. 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
;�h
uilding. Check one of the boxes below:.
and-sketch in the area below
❑ drawing attached separately /
( E
#ell
I
I
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Commonwealth of Massachusetts
ect'®� ® ren
Title 5 official Insp. r Assessments
Subsurface Sewage Disposal System Form -Not for Voluntary
286 Midpine Road, Barnstable, MA
Property Address
Elizabeth C Constantino, P. O. Box 54, Cummaquid, MA 02637 12/0412020
Owner Owner's Name MA 02630
information is Barnstable Zip Code Date of Inspection
state
required for every City(fown
page.
D. System Information (gon .
15. Site Exam: y
Check Slope
❑ Surface water
❑ Check cellar
f
❑ Shallow wells �Z ;
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: 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:
7•�D l`'.J G l�Ls1
you est blish d the high ground water elevation:
You must describe how y
a 7
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
Title 5 offidai Inspection Form:Subsurface Sewage Disposal System..Page 17 of 18
t5insp"doc•rev.726R018
c Commonwealth of Massachusetts
Title 5 off icial Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
286 Midpine Road, Barnstable, MA
Property Address
Elizabeth C Constantino, P. O. Box 54, Cummaquid, MA 02637
Owner Owner's Name
informations Barnstable MA 02630 12/04/2020
required for every
page. Cityffown State Zip Code Date of Inspection
E. Report Completeness Checklist
Comp to all applicable sections of this form inclusive of:
A. Inspector Information: Complete all fields in this section.
�. B. Certification: Signed &Dated and 1, 2, 3, or 4 checked
�] C. Inspection Summary:
1,2, 3, or 5 completed as appropriate
4(Failure Criteria)and 6(Checklist)completed
r
D. System Information:
For 8:Tight/Holding Tank—Pumping contract attached
t
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
4
I�
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
Commonwealth of Massachusetts
�x Title 5 Official Inspection Form
ie Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Fes.
286 Mid Pine Road, Cummaquid M -349 P -24
u� Property Address t
Elizabeth Constantino ?
Owner Owner's Name
information is
required for every P.O. Box 54, Cummaquid MA 02637 June 6, 2019 ,
page. City/Town State Zip Code Date of Inspection F
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. Inspector Information 5�, a(a
filling out forms
on the computer,
use only the tab Troy Williams
key to move your Name of Inspector
cursor-do not Troy Williams Septic Inspections
use the return Company Name
key.
Hummel Drive
r� Company Address -
South Dennis MA 02660
City/Town State Zip Code
100 (508) 385 - 1300 S1682
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
_ June 6, 2019
Inspectors ignature 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 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 form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: 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.
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
Commonwealth of Massachusetts
�^ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
286 Mid Pine Road, Cummaquid M -349 P-24
Property Address
Elizabeth Constantino
Owner Owner's Name
information is required for every ummaq p O. Box 54, C uid MA 02637 June 6, 2019
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) 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:
System meets minimum standards set by Massachusetts DEP at the time of inspection only.This
inspection is not a guarantee or warranty on the future working conditions of leaching, pipes,
components or the future structural integrity of said components and only represents conditions found
at the time of inspection only.
2) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
Commonwealth of Massachusetts
: Title 5 Official Inspection Form
iIa Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
286 Mid Pine Road, Cummaquid M -349 P -24
Property Address
Elizabeth Constantino
Owner Owner's Name
information is q
required for every P.O. Box 54, Cumma uid MA 02637 June 6, 2019
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ 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):
3) 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.
a. 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:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
it
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
286 Mid Pine Road, Cummaquid M - 349 P -24
Property Address
Elizabeth Constantino
Owner Owner's Name
information is q required for every P.O. Box 54, Cumma uid MA 02637 June 6, 2019
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ 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
b. 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.
❑ 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.
c. Other:
4) 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
��� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
286 Mid Pine Road, Cummaquid M -349 P-24
V
Property Address
Elizabeth Constantino
Owner Owner's Name
information is q
required for every P.O. Box 54, Cumma uid MA 02637 June 6, 2019
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® 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:
❑ ® "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.
El ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
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 2000 gpd-
10,000 gpd.
❑ ® 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.
5) 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 CA.
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
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection!Form:Subsurface Sewage Disposal System-Page 5 of 18
Commonwealth of Massachusetts
�r Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
286 Mid Pine Road, Cummaquid M - 349 P -24
Property Address
Elizabeth Constantino
Owner Owner's Name
information is q
required for every P.O. Box 54, Cumma uid MA 02637 June 6, 2019
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a signifibant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
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)]
i
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
286 Mid Pine Road, Cummaquid M - 349 P -24
Property Address
Elizabeth Constantino
Owner Owner's Name
information is
required for every P.O. Box 54, Cummaquid MA 02637 June 6, 2019
page. City/Town State Zip Code Date of Inspection
D. System Information
1. 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
Description:
f
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to: N/A
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 ears usage d 18=44,000 gals.
g ( y g (gpd)): 17=41,000 gals.
Detail
Sump pump? ❑ Yes ® No
Last date of occupancy: occupied
Date
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
rn ,,
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
' 286 Mid Pine Road, Cummaquid M -349 P -24
Property Address
Elizabeth Constantino
Owner Owner's Name
information is q required for every P.O. Box 54, Cumma uid MA 02637 June 6, 2019
page. City/Town State Zip Code Date of Inspection
D: System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment: N/A
Design flow(based on 310 CMR 15.203): N/A
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.): N/A
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to: N/A
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available: N/A
Last date of occupancy/use: N/A
Date
Other(describe below):
N/A
3. Pumping Records:
Source of information:
Pumped 10/12/16
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
r
286 Mid Pine Road, Cummaquid M - 349 P -24
Property Address
Elizabeth Constantino
Owner Owner's Name
information is required for every P.O. ummaq p O Box 54, C uid MA 02637 June 6, 2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. 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):
no d-box
Approximate age of all components, date installed (if known) and source of information:
Tank and leaching are original to home built approx. 1975.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
18"
Depth below grade: feet
Material of construction:
® cast iron _® 40 PVC orangeburg
® other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Flushed lines and found clear at the time of inspection. Note: Orangeburg pipe is prone to root growth
and other problems that may be of concern in the future.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
,�,A Title 5 official Inspection Form
�1� Subsurface Sewage Disposal System Form :Not for Voluntary Assessments
286 Mid Pine Road, Cummaquid M - 349 P -24
Property Address
Elizabeth Constantino
Owner Owner's Name
information is P.O. Box 54, Cumma uid MA 02637 June 6, 2019
required for every q
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank (locate on site plan):
1'
Depth below grade: 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:
6'X10.5'X6' 1500 gallon ;
Sludge depth: 4"
Distance from top of sludge to bottom of outlet tee or baffle
2' 8"
Scum thickness thin layer
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
16"
How were dimensions determined?
probe/measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Concrete inlet baffle and outlet tee were found present and in working order. No evidence of leakage
or damage was found. Tank was not in need of pumping at this time.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 13
f
Commonwealth of Massachusetts
:. Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
286 Mid Pine Road, Cummaquid M -349 P -24
Property Address
Elizabeth Constantino
Owner Owner's Name
information is required for every P.O. Box 54, ummaq C uid MA 02637 June 6, 2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: N/Afeet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene. ❑ other(explain):
Dimensions:
N/A
Scum thickness N/A
Distance from top of scum to top of outlet tee or baffle N/A
Distance from bottom of scum to bottom of outlet tee or baffle N/A
Date of last pumping: N/A
Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
N/A
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: N/A
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
N/A
Capacity: N/A
gallons
Design Flow: N/Agallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 ,
i
t
i
Commonwealth of Massachusetts
�x ,��,p Title 5 Official Inspection Form
r,
I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
/;
V � 286 Mid Pine Road, Cummaquid M - 349 P -24
Property Address
Elizabeth Constantino
Owner Owner's Name
information is q
required for every P.O. Box 54, Cumma uid MA 02637 June 6, 2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: N/A Alarm in working order: ❑ Yes ❑ No
Date of last pumping: N/A
Date
Comments (condition of alarm and float switches, etc.):
N/A
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. 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.):
Snaked line with no d-box found.
t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
lip"
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
286 Mid Pine Road, Cummaquid M -349 P-24
�—
Property Address
Elizabeth Constantino
Owner Owner's Name
information is required for every P.O. Box 54, Cummaquid MA 02637 June 6, 2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
r
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
N/A
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why: -
Type:
® leaching pits number: 1 -6'X6' pit with
2 of 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:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
286 Mid Pine Road, Cummaquid M -349 P-24
Property Address
Elizabeth Constantino
Owner Owner's Name
information is q required for every P.O. Box 54, Cumma uid MA 02637 June 6, 2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soil was sandy. Leach pit was found with 3.0' of water present with a visible stain line approx. 2'
below inlet invert. No evidence of hydraulic failure or problems in the past were found at the time of
inspection. Some root growth found present around inet pipe. Telephone line located over cover.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration N/A
Depth —top of liquid to inlet invert N/A
Depth of solids layer N/A
Depth of scum layer N/A
Dimensions of cesspool N/A
Materials of construction N/A
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/A
i
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 1'8
Commonwealth of Massachusetts
. Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
286 Mid Pine Road, Cummaquid M - 349 P -24
Property Address
Elizabeth Constantino
Owner Owner's Name
information is q
required for every P.O. Box 54, Cumma uid MA 02637 June 6, 2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan): .
Materials of construction: N/A
Dimensions N/A
Depth of solids N/A
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/A
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
i
Commonwealth of Massachusetts
�a Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form :Not for Voluntary Assessments
.......... 286 Mid Pine Road, Cummaquid _ _ M -349 P-24 _
Property Address
Elizabeth Constantino
Owner Owner's Name
information is P.O. Box 54 Cummaquid MA 02637 June 6 2019
required for every � _ _
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. 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.
w ❑ drawing attached separately
r9 I j
FI
Fal
31,
-76
3
3 � �
r
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts ,
Title 5 Official Inspection Form
14 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
, u 286 Mid Pine Road, Cummaquid M - 349 P-24
Property Address
Elizabeth Constantino
Owner Owner's Name
information is q
required for every P.O. Box 54, Cumma uid MA 02637 June 6, 2019
page. City/Town State , Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
13.0'+
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: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain: j
❑ Checked with local excavators, installers - (attach documentation)
® Accessed USGS database -explain:
AIW 247 Zone C 21.0' .4' adjustment
You must describe how you established the high ground water elevation:
Hand augered 4' below bottom of leaching with no water found at a depth of 13.0'. Groundwater
adjustment at the time of inspection was .4'. Bottom of leaching at 9.0'was found not to be located in
the high groundwater elevation at the time of inspection. USG_ S maps for Barnstable show
groundwater at approx..15.0'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
_ f
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments -
286 Mid Pine Road, Cummaquid M -349 P -24
Property Address
Elizabeth Constantino
Owner Owner's Name
information.is required for every P.O. Box 54, ummaq C uid MA 02637 June 6, 2019
page. City/Town State Zip Code. Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
TOWN OF BARNSTABLE m
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NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-.Not for Voluntary Assessments
286 Mid Pine Road, Cummaquid M-349 P-24 O
Property Address C
Elizabeth Constantino o
Owner Owner's Name ►.a
information is P O. BOX 54 AIINS
required for every , Cummaquid �VIA 02637 October 27, 2016
page. City/Town State Zip Code Date of Inspection �
W.
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at,the end of the form.
Important:When A. General Information
filling out forms •
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Troy Williams
key the return Name of Inspector
Y
Troy Williams Septic Inspections
Company Name
19 Hummel Drive
Company Address •
South Dennis MA 02660
City/Town State 'Zip Code
(508) 385- 1300 S1682
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
❑ Needs Further Evaluation by the Local Approving Authority
. I
October,27, 2016
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 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. .
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
�o Z
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
0 �'( 286 Mid Pine Road, Cummaquid M-349 P-24
" Property Address
°a Elizabeth Constantino
Owner Owner's Name
information is
r- required for every P.O. Box 54 , Cummaquid MA 02637 October 27, 2016
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:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
System meets minimum standards set by Massachusetts DEP at the time of inspection only.This
inspection is not a guarantee or warranty on the future working conditions of leaching, pipes,
components or the future structural integrity of said components and only represents conditions found
at the time of inspection only.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
286 Mid Pine Road, Cummaquid M-349 P-24
Property Address
Elizabeth Constantino
Owner Owner's Name
information is
required for every P.O. Box 54 , Cummaquid MA 02637 October 27, 2016
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup'or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below).-
El The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
ti r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
286 Mid Pine Road, Cummaquid M-349 P-24
Property Address
Elizabeth Constantino
Owner Owner's Name
information is
required for every P.O. Box 54 , Cummaquid MA 02637 October 27, 2016
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 the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than,100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts h
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form 7 Not for Voluntary Assessments
286 Mid Pine Road, Cummaquid M' 349 P-24
Property Address
Elizabeth Constantino
Owner Owner's Name
information is p O. Box 54 , Cummaquid MA 02637 October 27F
required for every � ,'2016 -
page. Cltyrrown 'State Zip Code Date of Inspection
B. Certification (cont.)
Yes No ;
❑ ® Required pumping more than 4 times in the last year NOT due to cloggedor,
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS_, cesspool or�privy is below high ground water elevation.
f
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water,supply or
tributary to a surface water supply.
❑ ®' Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is,less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis[This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd T
10,000gpd.
❑ ® The system fails. I have determined that one or.more of the above failure
criteria-exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with'a e
design flow of 10,000 gpd to 16,000 gpd.
For large systems, you must indicate either,"yes"or"no"to,each of the following, in addition to the
questions in Section D. :• ,_
Yes No ._
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ - ❑ the system is within 200 feet of.a tributary to,a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection
' ❑ .,-'Area—IWPA).or a mapped,Zone*II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or-operator of any large
system considered a significant threat under Section E or failed under Section,D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins%3/13 , Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y 286 Mid Pine Road, Cummaquid M-349 P-24
Property Address
Elizabeth Constantino
Owner Owner's Name
information is
required for every 54 ,P O. Box
Cummaquid MA 02637 October 27, 2016
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ 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): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 gpd
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form .
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
286 Mid Pine Road, Cummaquid M-349 P-24
Property Address
Elizabeth Constantino
Owner Owners Name
information is required for every P.O. Box 54 , Cummaquid MA 02637 October 27, 2016
page. Cityrrown State Zip Code Date of Inspection
D. System Information '
Description:
r-
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d " 15=41,000 gals.
g ( y g (gp ))' 14=41,000 gals.
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: occupied
Date
Commercial/industrial Flow Conditions:
Type of Establishment: N/A
N/A
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.): N/A _
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: N/A
t5ins-3/13 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
286 Mid Pine Road, Cummaquid M-349 P-24
Property Address
Elizabeth Constantino
Owner Owner's Name
information is P O. Box 54
required for every , Cummaquid MA 02637 October 27, 2016
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: N/A
Date
Other(describe below):
N/A
General Information
Pumping Records:
Source of information: Last pumped on 10/12/16 per info from owner.
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):
no d-box
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
IFTitle '5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
286 Mid Pine Road, Cummaquid fi M-349 P-24
Property Address
Elizabeth Constantino
Owner Owner's Name
information is
required for every P.O. Box 54 , Cummaquid MA 02637 October 27, 2016
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
Tank and leaching are original to home built approx. 1975.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 18"+
feet
Material of construction:
® cast iron ®40 PVC ® other(explain): orangeburg
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Flushed lines and found clear at the time of inspection. Note: Orangeburg pipe is prone to root growth
and other problems that may be of concern in the future.
Septic Tank(locate on site plan):
Depth below grade: 14
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: 6'X10.5'X6' 1500 gallon
,
Sludge depth: 4"
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM ' 286 Mid Pine Road, Cummaquid M-349 P-24
Property Address
Elizabeth Constantino
Owner Owner's Name
information is
reg uire for for every P.O. Box 54 , Cummaquid MA 02637 October 27, 2016
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
2'8"
Scum thickness none
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
14"
How were dimensions determined?
probe/measured
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Concrete inlet baffle and outlet tee were found present and in working order. No evidence of leakage
or damage was found. Tank was not in need of pumping at this time.
Grease Trap(locate on site plan):
Depth below grade: N/A
feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
N/A
Scum thickness N/A
Distance from top of scum to top of outlet tee or baffle N/A
Distance from bottom of scum to bottom of outlet tee or baffle N/A
Date of last pumping: N/ADate
t5ins•3113 Title 5 Official Inspection 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
•'� 286 Mid Pine Road, Cummaquid M-349 P-24
Property Address
Elizabeth Constantino
Owner Owner's Name
information is every
P.O. BOX 54
required for eve , Cummaquid MA . 02637 October 27, 2016
page. Citylrown State Zip Code Date of Inspection
D. System Information (coat.)
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: N/A
Material of construction:
❑ concrete ❑ metal ❑fiberglass ;❑ polyethylene ❑other(explain):
N/A
Dimensions:
-Capacity: N/A
gallons
Design Flow: N/A
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: N/A Alarm in:working order: ❑ Yes ❑ No
Date of last pumping: N/A
Date
Comments_ (condition of alarm and float switches, etc.):
N/A ,
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes No
t5ins•3113 . Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
286 Mid Pine Road, Cummaquid M-349 P-24
Property Address
Elizabeth Constantino
Owner Owner's Name
information is p O. Box 54 , Cummaquid MA 02637 October 27 2016
required for every ,
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
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.):
Snaked line with no d-box found.
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.):
N/A
*If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System(SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
JD
TIf Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
.•'' 286 Mid Pine Road, Cummaquid M-349 P-24
Property Address
Elizabeth Constantino
Owner Owner's Name
ion is required
P O. Box 54 C
re equir wiredd for eve ummaquid MA 02637 October 27, 2016
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1 -6'X6' pit with 2' of 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 was found with 2.8'of water present with a visible stain line approx. 2.5' below inlet invert.
No evidence of hydraulic failure or problems in the past were found at the time of inspection. Some
root growth found present around inet pipe. Telephone line located over cover.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration N/A
Depth—top of liquid to inlet invert N/A
Depth of solids layer N/A
Depth of scum layer N/A
Dimensions of cesspool N/A
Materials of construction N/A
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
,M 286 Mid Pine Road, Cummaquid M-349 P-24
Property Address
Elizabeth Constantino
Owner Owner's Name
information is required for every P.O. Box 54 Cummaquid MA 02637 October 27, 2016
page. Cityrrown 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.):
N/A
Privy(locate on site plan):
Materials of construction: N/A
Dimensions N/A
Depth of solids N/A
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/A
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form •
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
286 Mid Pine Road, Cummaquid M-349 P-24
Property Address
Elizabeth Constantino `
Owner Owner's Name
information is
required for every P.O. Box 54 , Cummaquid MA ` 02637 . October 27, 2016
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below_
❑ drawing attached separately
4 ❑
Z
3; ? 6 �
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
286 Mid Pine Road, Cummaquid M-349 P-24
Property Address
Elizabeth Constantino
Owner Owner's Name
information is
required for every 54 ,P.O. Box
Cummaquid, MA 02637 October 27, 2016
page. City/Town State Zip Code Date of Inspection
D. System Information (cant.)
Site Exam:
® Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
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: 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:
AIW 247 Zone C 24.9' 5.6'adjustment
You must describe how you established the high ground water elevation:
Hand augered 6' below bottom of leaching with no water found at a depth of 15.0'. Groundwater
adjustment at the time of inspection was 5.6'. Bottom of leaching at 9.0'was found not to be located
in the high groundwater elevation at the time of inspection. USGS maps for Barnstable show
groundwater at approx. 15.0'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
286 Mid Pine Road, Cummaquid M-349 P-24
Property Address
Elizabeth Constantino
Owner Owner's Name
information is required for every P.O. Box 54 , Cummaquid MA 02637 October 27 2016
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
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