HomeMy WebLinkAbout0101 OLD JAIL LANE - Health "101�Oid�Jail Lane
Barnstable P � A
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
d DEPARTMENT OF ENVIRONMENTAL PROTECTION
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TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 101 Old Jail Lane,Barnstable,MA 02630 _
Owner's Name: Noel Girouard
Owner's Address: 101 Old Jail Lane,Barnstable,MA 02630
Date of Inspection: 01/10/2007 ra
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Name of Inspector:Michael T.Bisienere
Company Name:A&K Septic Systems Plus i
Mailing Address: 565 Carriage Shop Road,East Falmouth,MA 02536
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Telephone Number: 508-540-6706
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
X Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: . Date: 1-11®7
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health oz '
_ _ --- --_ _
e system is a shared system-or has-a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments: There is no evidence of hydraulic failure.
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 101 Old Jail Lane,Barnstable,MA 02630
Owner: Noel Girouard
Date of Inspection: 01/10/2007
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303
or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken;settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(sl are rep ace I
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Title 5 Inspection Form 6/15/2000. 2
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 101 Old Jail Lane,Barnstable,MA 02630
Owner: Noel Girouard
Date of Inspection: 01/10/2007
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.
I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
— The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free-from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
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Title 5 Inspection Form 6/15/2000 3
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Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 101 Old Jail Lane,Barnstable,MA 02630
Owner: Noel Giouard
Date of Inspection: 01/10/2007
D. System Failure Criteria applicable to all systems:
You must indicate-"yes"or"no"to each of the following for all inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_ X Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a,surface
water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well
X 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
No (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
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E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
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(The following criteria apply to large systems in addition to the criteria above)
yes no
- _ the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well t
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. j
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Title 5.Inspection Form 6/15/2000 4 P
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Page 5 of 11
OFF
ICIAL INS
PECTION
ECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 101 Old Jail Lane,Barnstable,MA 02630 .
Owner: Noel Girouard
Date of Inspection: 01/10/2007
Check if the following have been done.You must indicate"yes"or"no'as to each of the following:
Yes No
X — Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out.in the previous two weeks?
X — Has the system received normal flows in the previous two week period?
-2L Have large volumes of water been introduced to the system recently or as part of this inspection?
X Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X — Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out?
X — Were all system components,excluding the SAS,located on site?
X — 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?
X _ Was the facility owner(and occupants if different from owner)provided with information on the
proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
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——----- xis iiig in ormation.-For example,-a plan at the_Board of Health.
X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)]
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Title 5 Inspection Form 6/15/2000 5 f
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 101 Old Jail Lane,Barnstable,MA 02630
Owner:Noel Girouard
Date of Inspection: 01/10/2007
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):440
Number of current residents:3
Does residence have a garbage grinder(yes or no): No.
Is laundry on a separate sewage system(yes or no):No. [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use: (yes or no): No.
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no): No
Last date of occupancy: Current.
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Home Owner
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped:,How was quantity pumped determined? 1500 gal.-2004
Reason for pumping:Maintenance
TYPE OF SYSTEM
Mfloution DOX,sol -a Sorption system _.-
Single cesspool
_ Overflow cesspool
Privy
Shared system(yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Alternative technology.Attach.a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank Attach a copy of the DEP approval
Other(describe): ,
Approximate age of all components,date installed(if known)and source of information: {
Were sewage odors detected when arriving at the site(yes or no): �.
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Title 5 Inspection Form 6/15/2000 6
Page 7ofII
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 101 Old Jail Lane,Barnstable,MA 02630
Owner:Noel Girouard
Date of Inspection: 01/10/2007
BUILDING SEWER(locate on site plan)
Depth below grade: 3"
Materials of construction: cast iron X 40 PVC _other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK (locate on site plan)
Depth below grade:6"
Material of construction: X concrete metal fiberglass—polyethylene.
_other (explain) —
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):
certificate) —(attach a copy of
Dimensions: 5'8"x 10'10"
Sludge depth: 1"
Distance from top of sludge to bottom of outlet tee or baffle: 39"
Scum thickness: '/2"
Distance from top of scum to top of outlet tee or baffle: 8"
Distance from bottom of scum to bottom of outlet tee or baffle: I I"
How were dimensions determined: Tape i
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
GREASE TRAP:NA(locate on site plan)
Depth below grade:—
Material of construction:_concrete . metal fiberglass_polyethylene other
(explain): — - —
Dimensions:
Scum thickness:
Distance from top of scurm,�to top of outlet tee or baffle::
1Ctilfl!`P
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Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM i
Title 5 Inspection Form 6/15/2000 7
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Page 8 of 11
PART C
SYSTEM INFORMATION(continued)
Property Address: 101 Old Jail Lane,Barnstable,MA 02630
Owner:Noel Girouard
Date of Inspection:01/10/2007
TIGHT or HOLDING TANK: NA (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no): '
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 0
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.):
PUMP CHAMBER: NA(locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
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Title 5 Inspection Form 6/15/2000 8
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 101 Old Jail Lane,Barnstable,MA 02630
Owner: Noel Girouard
Date of Inspection:01/10/2007
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
X leaching chambers,number:4-500 chambers
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:-
Depth of scum layer:-
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
i
PRIVY: NA (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
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Title 5 Inspection Form 6/15/2000 9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 101 Old Jail Lane,Barnstable,MA 02630
Owner: Noel Girouard
Date of Inspection:01/10/2007
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
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Title 5 Inspection Form 6/15/2000 10
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 101 Old Jail Lane,Barnstable,MA 02630
Owner: Noel Girouard
Date of Inspection: 01/10/2007
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water: 10 PLUS FEET
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established: augered hole to 10'
5Ud qai.
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Title 5 Inspection Form 6/15/2000 11
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COMMONWEALTH OF MASSACHUSETTS AFFAIRS
EXECUTIVE OFFICE OF ENVIRONMENTAL A
DEPARTMENT OF ENVIRONMENTAL PROTECTION
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TITLE 5
OFFICIAL INSP SYSTEM
ECTION FORM—NOT FOR VOLUNTARY OR SEKED
SUBSURFACE SEWAGE DISPOSAL SYS f MAY 14 2002
PART A
CERTIFICATION TOWN OF BARNSTABLE
HEALTH DEPT.
Property Address: lot OLD JAIL LN BARNSTABLE, MA 02630
Owner's Name: SHIPMAN
Owner's Address: REALTY EXECUTIVES 1582 RT 132 HYANNIS MA 02601
Date of Inspection: 4/10/02
Name of Inspector: (pleasc�p:rint),_ JOHN GRACI 7.- a
SEPTIC INSPECTIONS MAP �J
Company Name: :. 0 5 Z
Mailing Address: t� P.O.�BOX 2119 TEATICKET,MA.02536 PARCH. '
Telephone Number: 508-564-6813 FAX 508-564-7270
LOT
CERTIFICATION STATEMENT
I certify that I have personally inspected the-sewage disposal system ins inspection was performed based on myttrraining and below is
true,accurate and complete as of the time'of the inspection.The p ills. I am a DEP approved system
experience in the proper function and mafrTenle Se of on site 310 CMRsewage disposal The systei r
inspector pursuant to Section 15.340 o
X Passes
_ Conditionally Pas s y Authority
_ Needs Furthe aluation b the Local Approving
_ EaiIs
Date: 4/10/02
Inspector's Signature: �� (Board of Health or DEP)within
The system inspector shall submi a copy of this inspection report to the Approving Authority(Boa
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 apprepand the ariate loprov nnal fg authoce of lrit DEP. The original should be
P p
sent to the system owner and=copies sent,to the buyer, if applicable,
Notes and Comments
SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING NO
`V AND THEN EVERY TWO YEARS T
PROLONG THE SYSTEM'S USEFUL LIFE. ndit -
****This report only describes conditions at the time of inspection re uudcdr thle coe same or11different conditions'If Usca( that ns of use.
P
inspection does not address how tFe system will perform in the Tutu
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Page 2 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS j
SUBSURFACE SEWAGE DISPOSAL SYSTEM I` `':PECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 101 OLD JAIL L'N BARNSTABLE, MA 02630
Owner: SHIPMAN
Date of Inspection: 4/10/02
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Sectioa D
A. System Passes: a
X 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 PASSES TITLE V INSPEC yr10N. RECOMMEND PUMPING NO' ,\ND THEN EVERY TWO YEARS
TO PROLONG THE SYSTEM'S USEFUL LIFE.
B. System Conditionally Passes:
_ One or more system components as described in the"Conditional Pass"section r:;ed to be replaced or repaired.The system,
upon completion of the replacement or repair,as approved by the Board of Health,w;ll pass.
h following statem ents. If not determined lease explain.
YNND in the for ep p
Answer es no or not determined
Y ( )
n/a The septic tank is metal and over 20� /ears old* or the septic tank(whether metal or not) is structurally unsound,exhibits
will ass inspection if the existing tank is replaced
substantial infiltration or exfiltration or tank failure is imminent. S stem p p g p
subs Sy
stern
a complying se tic tank as approved by.the Board of Health.
p
* of Compliance indicating
i i structural) sound not leaking and if a Certificate g
A metal septic tank will pass inspection �f i s y g p
that the tank is less than 20 years old is available.
ND explain: n/a
n/a Observation of sewage backup or break out.or high static water level in the di3u ibution 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 pipes)are replaced
_ obstruction is removed
_ distribution box is leveled or replaced
ND explain: n/a
n/a The system required pumping more thar 4 times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
`broken pipe(s)are replaced
_obstruction is removed
ND explain: n/a
Page 3 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
'k CERTIFICATION(continued)
Property Address: 101 OLD JAIL LN BARNSTABLE,MA 02630
Owner: SHIPMAN
Date of Inspection: 4/10/02
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 n
2. System will fail unless the Board of Health(and Public Water Supplies,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 wafer supply.
The system has a septic tank and SAS'and the SAS is within a Zone I of a l;iblic water supply.
_ The system has a septic tank and S-AS 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 bui 50 feet or more from a private water
supply well". Method used to determine distance n/a
"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and
volatile organic comp'oUnds indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy
of the analysis must be attached fo'this form.
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3. Other:
n/a i;
Page 4 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM
4• PART A
CERTIFICATION(continued)
Property Address: 101 OLD JAIL LN BARNSTABLE, MA 02630
P Y
Owner: SHIPMAN
Date of Inspection: 4/10/02
D. System Failure Criteria applicable to all systems:
You mast indicate"yes"or"no"to each of the following for all-inspections:
Yes No '`-
X Backup of sewage into:facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than.''/z day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped Wa.
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X 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 coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from thatifacility 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 forma `
(Yes/No)The system fails l 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 design flow of 10,000 gpd to 15,000 gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
_ X the system is within 400 feet of a,surface drinking water supply
X the system is within 200feet of a tributary to a surface drinking water supply
_ X the system is located in a nitrogen'sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone 11 of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"ycs" in Section D above the large systcli.i lias faile(l. 'I'lle owner rn•t►hernlor of nny large crnl:5i(lererl n siknifirmit threat
1.
under Section E or failed under Section n shall upgrade the system in acco l-danc('.will) 310('W 15•'1011 'I l)[•sysi[•ni [mnvr
should contact the appropriale rcltiimal nllicr nI IhC I IrlHnlln['lll
,w
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' Page 5 of 1
=a
OFFICIAL INSPECTION'FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 101 OLD JAILLN BARNSTABLE,MA 02630
Owner: SHIPMAN
Date of inspection: 4/10/02
Check if the following have been done. You must indicate "yes" or"no" as to eacF,Jf'che following:
4r
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Flealth
X Were any of the system.1components pumped out in the previous two weeks
X _ Has the system received normal flows in the previous two week period?
X Have large volumes of water;been introduced to the system recently or as r:rt of this inspection ?
X _ Were as built plans of the system obtained and examined?(If they were ric:•t available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out
X _ Were all system components,excluding the SAS, located on site'?
X _ Were the septic tank manholes uncovered,opened, and the interior of the,:aak inspected for the condition of the
baffles or tees, material of construction,dimensions, depth of liquid,depth of sluda and depth of scum?
X _ Was the facility owner(and occupants if different from owner)provided v, th information on the proper maintenance
of subsurface sewage disposal systems
The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
Yes no
X _ Existing information: For example,a plan at the Board of Health.
X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is
unacceptable) [310 CMR 15.302(3)(b)]`
d . ,
Page 6 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 101 OLD JAIL LN,BARNSTABLE, MA 02630
Owner: SHIPMAN
Date of Inspection: 4/10/02
FLOW CONDITIONS
RESIDENTIAL ;
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.2Q3 (for,example: 110 gpd x#of bedrooms): 440
Number of current residents: 4
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or n4`11NO
Seasonal use: (yes or no): NO
Water meter readings, if available(last 2 years usage(gpd)):i 'DO- l QS t OUP
Sump pump(yes or no): NO
Last date of occupancy: n/a LM I - 110i 00c)
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR 15'.203): n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to the Title 5 system(yes or no): NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a x'
GENERAL INFORMATION
Pumping Records
Source of information: n/a
Was system pumped as part of the inspection.('yes or no): NO
If yes,volume pumped: n/agallons-- How was quantity pumped determined? n/a
Reason for pumping: n/a
fig. •q��:
TYPE OF SYSTEM
X 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 mil:tenance contract(to be obtained from
system owner)
Tight tank Attach a copy of the DEP approval
Other(describe): n/a
Approximate age of all components,date ins failed(if known)and source of informnon:
1998 BY AGENT PERMIT 98-508
Were sewage odors detected when arriving al Ilic,silc (ycr ur wo: No
a.
v 6t
Page 7 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 101 OLD JAIL LN BARNSTABLE,MA 02630
Owner: SHIPMAN
Date of Inspection: 4/10/02
BUILDING SEWER(locate on siteplan) "
Depth below grade: 20"
Materials of construction:_cast iron X40 PVC;.other(explain): n/a
Distance from private water supply well or suction line: n/a
Comments(on condition of joints, venting,evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: X(locate on site plan)
Depth below grade: 14"
Material of construction: Xconcrete metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: 150OG L 10' 6" H 5' 6" W 5' 8= .
Sludge depth: 3"
Distance from top of sludge to bottom of outlet,tee or baffle: 31"
Scum thickness: 5"
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: 13"
How were dimensions determined: 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.)-
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.
RECOMMEND PUMPING NOV1" ND THEN EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL
LIFE.
GREASE TRAP: _(locate on site plan)
Depth below grade: n/a '
Material of construction:_concrete_meiau_fiberglass_polyethylene_other(explain): n/a
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
b
Date of last pumping: n/aa
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
Page 8 of I l
1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE;SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 101 OLD JAIL LN BARNSTABLE, MA 02630
Owner: SHIPMAN
Date of Inspection: 4/10/02
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: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX:X(if present'(nust be opened)(locate on site plan)
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
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.):
D-BOX IS STRUCTURALLY'SO'UND
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber;,condition of pumps and appurtenances,etc.):
r
n/a
e
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•i,
x •
Page 9 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM IN' PECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 101 OLD JAIL LN BARNSTABLE,MA 02630
Owner: SHIPMAN
Date of Inspection: 4/10/02
SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
n/a leaching pits, number: n/a
500 GALLON DRYWELLS leaching chambers, number: 4
n/a leaching galleries, number: rila
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a innovative/alternative system
Type/name of technology: n/a
i" ' l of ponding,dam soil,condition of vegetation,etc.):
Comments(note condition of soil,signs of hydraulic failure, level p g, p
DRYWELLS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS
OF FAILURE. BOTTOM AT 6'
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 or no): NO
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
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM I , IPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 101 OLD JAIL LN BARNSTABLE, MA 02630
Owner: SHIPMAN
Date of Inspection: 4/10/02
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permarxc;t reference landmarks or benchmarks.
Locate all wells within 100 feet. Locate where public water supply enters the build;:i�.
Q fi
Y
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Page I 1 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 101 OLD JAIL 6. BARNSTABLE,MA 02630
Owner: SHIPMAN
Date of Inspection: 4/10/02
SITE EXAM
_Slope e ,
_Surface water
_Check cellar
Shallow wells '
Estimated depth to ground water 12+feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a
YES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavatdrs, installers-(attach documentation)
NO Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
HAND AUGER- 12+ FT.
N
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` No. �R `-� ` Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
ZippYication for Miopotar *paem Comet uction permf/
Application for a Permit to Con stru ( R ai )Upgr e )Abandon t ¢� �� ( ) Complete System El Individual Components
Location Address or Lot No.Lp 7' QLp J'4/L LAl Owner's Name,Address and Tel.No.
Assessor's Map/Parcel M,Z78 S(o o d!7?+
x /�¢ � .s?vJB�� 4—'Z8o-4734 '
Installer's Name,Address,and Tel.No. ) '/ Designer's Name,Address and Tel.No.
-�jc`f - i ,66AI.Sl
S�a�wt�cl,. /A LA palp
Type of Building:
Dwelling No.of Bedrooms Lot Size Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow //0 )06-12- ,664461W,,0/29 gallons per day. Calculated daily flow 4!!jj�-® gallons.
Plan Date Number of sheets / Revision Date
Title /S" ,J.4G 12 �T�,�iE� GClL
Size of Septic Tank C044 Type of S.A.S.
Description of Soil �L�(DJ�✓/p�rS��,D
law
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Enviro mental Code and not to place the system in operation until a Certifi-
cate of Compliance has been iss py his Boar alt
Signed Date �' 4
Application Approved - Date a
Application Disapproved for the following reasons
Permit No. Date Issued
TOWN OF
LOCATION: L �' �^ 0%rJ
VILLAGE: rh (f�
LOT # : *)).1*, 0 G, - 60 3-- PERMIT # : ��- 5-0
INSTALLER' S NAME: -,l4
INSTALLER' S PHONE # :
LEACHING FACILITY: (type) (size) y
NO. OF BEDROOMS: L
BUILDER OR OWNER:
PERMIT DATE:
COMPLIANCE DATE:
DRAW DIAGRAM ON BACK
Jd
aK ,.,, ,.ti�t� ,�:.��,; ,�S' :.►��Itrv;..,..-,X+ a.�,+.+t,,M#w i, �.�.s r�.f,�'*'�,`i�+�,l<9W.+�vj,�."�,;P �+,y ,.`'^-..-Bµ"3'aL.,,,. �<`• tn,G � _y,IF�"d;ti.,. ;a..cn� .a,�:rtxn•a&F.r��S k
No. Fees
a ' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ti
Yes
PUBLIC HEALTH DIVISION - TOWN OFBARNSTABLE, MASSACHUSETTS
ZIpplication for Mi.5pont *p$tem Co ngt UCtion Permtr
F Application for a Permit to Co sru�t( ) pgr e( ) Bandon( ) Complete System O Individual Components
1�
Location Address or Lot No.LOT Z OLD T,4/L Al( Owner's Name,Address ano Tel.No.
oirlF�3vC
F/7Z F0,4 TrA,6,A f�
Assessor'sMap/Parcel M, Z78'
Installer'' Name,Address,and Tel.No.3. p / J Designer's Name,Address and Tel.No.
� �f / eJTri.lf{ �`� ✓,�I�YLE f�SSOG/�T�S
Type oUBuilding:Dwelling No.of Bedrooms/ Lot Size +9 �o SS sq. ft. Garbage Grinder( )
Other Type of Building,` No.of Persons Showers( ) Cafeteria( )
Other Fixtures?
Design Flow /,0&/1- 6C-4/20,011) gallons per day. Calculated daily flow- }4'0 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank ��s�0 GAL Type of S.A.S. G11.41V13614
r, Q
Description of Soil
"- 3s`' s;-91A 6 Go•917I
'Nature of Repairs or Alterations(Answer when applicable)
Date last ms ected:
P..,
Agreement:
The undersigned agrees to.:ensure the construction-and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions oVitle 5 of the Envir nmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issue his Board'if.- alt�L.. \ t
li Signed Datef.
*, _ _..
Application Approved1 Date
Application Disapproved for the following reasons
Permit No.
'X, 'Date Issued k
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO C-E�R-TII-F�Y that the On-site Sewage Disposal System Constructed( )Repaired( ) Upgraded( )
` Abandoned( )by J
at has been,constructed in accordance
with the provisio s f Title 5 and the for Disposal System Construction Permit No. a dated '
Installer Cry y�11 S Designer U n c l
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date 4 p ~9 q Inspector�,�
No. � +�..��� -------- -- Fee e6�'
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE,,MASSACHUSETTS
xdi5potar *pgtem Construction Permit
Permission is hereby granted to Con truct( Repair( )Upgrade( )Abandon( )
1 -System located at - �o G �c< < A4 t
t ..
I
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions. ;
Provided:Construction must be completed within three years of the date of this permit.
Date:, Approved by
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TOWN OF Qi
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LOCATION: G � 0/0 )--ni
VILLAGE: �/ l
LOT # : �X j*- 0,7& d OU PERMIT # :
INSTALLER' S NAME: �..L�96�/��► I ,�' Cc 5
INSTALLER' S PHONE # :
LEACHING FACILITY: (type) xiov 71V (size) ��
NO. OF BEDROOMS: L
BUILDER OR OWNER: �a +.. 2 ;.
PERMIT DATE: ..
COMPLIANCE DATE:
DRAW DIAGRAM ON BACK
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