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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 15insp.doc-rev.7/26/2018 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 t5insp.doc•rev.7/2612018 Title 5 Official Inspec i n Form.Subsurface Sewage Disposal System•Page 16 of 18 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 "�- LOCATION �G / "` 4 6 L5- of ' SEWAGE # iYILLAGE vha y ✓ ASSESSOR'S MAP& LOT IgO4 -a2� INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) 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 Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) / Feet Furnished by w / I-N �.`�� (9' ���' 3�+' `� r � ,, �S �� � ,. t_-O CAA-T-ION -?g SEW--A GCE- E -MITU-0. rl ��� -77 D/�►TE-P-E-RI�/h-T-1_SSU-ED���- 7� - - - D-ATE:GO Nt-P-L 1-L1,I`l CE-t-SSU E-R:- �3 n 1. c!fi y . 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 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17