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HomeMy WebLinkAbout0045 OLD PHINNEY'S LANE - Health �1 ! A5�i,�1 Y -4 5"01&P]hi"ney#s Lan p A^� 1a;.�:�1M Barnstable;^� III Commonwealth of Massachusetts q7-6- 0023 W Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments _ 45 OLD PHINNEYS LANE Property Address SANTIAGO JOHN AND KELLY Owner Owner's Name 911 N information is MA 02630 07/07/2016. required for every BARNSTABLE page. Cityrrown State Zip Code Date of Inspection y� Inspection results must be submitted on this form. Inspection forms may not be altered)n any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not JOHN P GRACI SR use the return Name of Inspector key. GRACI SEPTIC INSPECTIONS LLC Company Name PO BOX 2119 Company Address TEATICKET MA 02536 Cityrrown State Zip Code 508-641-6694 S 1468 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 16.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluati y the Local Approving Authority 07/07/2016 Inspector's Signature j Date The system inspector shall s mit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 s of completing this inspection. If the system is a shared system or has a design flow of 10,000 g or greater, the inspector and theystem owner shall submit the report to the appropriate regi I 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 Commonwealth of Massachusetts a W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 45 OLD PHINNEYS LANE Property Address SANTIAGO JOHN AND KELLY Owner Owner's Name information is required for every BARNSTABLE MA 02630 07/07/2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM PASSES TITLE V INSPECTION.. 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): NA t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 45 OLD PHINNEYS LANE Property Address SANTIAGO JOHN AND KELLY Owner Owner's Name information is required for every BARNSTABLE MA 02630 07/07/2016 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or 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): NA ❑ 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): NA 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 w ❑ 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 Commonwealth of Massachusetts H W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 45 OLD PHINNEYS LANE Property Address SANTIAGO JOHN AND KELLY Owner Owner's Name information is required for every BARNSTABLE MA 02630 07/07/2016 page. City/Town 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: NA **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: NA 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 '/z day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 I Commonwealth of Massachusetts F W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 45 OLD PHINNEYS LANE Property Address SANTIAGO JOHN AND KELLY Owner Owner's Name information is required for every BARNSTABLE MA 02630 07/07/2016 page. Cityrrown State Zip Code Date of Inspection, B. Certification (cont.). Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary 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- 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 design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑,, the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ 0 the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 I Commonwealth of Massachusetts w W Title 5 Official Inspection- Form- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 45 OLD PHINNEYS LANE Property Address SANTIAGO JOHN AND KELLY Owner Owner's Name information is required for every BARNSTABLE MA 02630 07/07/2016 page. City/Town 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 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts H W Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 45 OLD PHINNEYS LANE Property Address SANTIAGO JOHN AND KELLY Owner Owner's Name information is required for every BARNSTABLE MA 02630 07/07/2016 page. City/Town State Zip Code Date of Inspection D. System Information Description: 1500 GALLON SEPTIC TANK DISTRIBUTION BOX AND (4) FOUR INFILTRATORS Number of current residents: (2)TWO 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.) Lau-ndry`system inspected? ❑ Yes E No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d TOWN 9 ( Y 9 (gP ))� , Detail A 2044- 24, 000 205. 24, oob Sump pump? ❑ Yes ® No Last date of occupancy: OCCUPIED Date Commercial/Industrial=Flow Conditions: Type of Establishment: NA Design flow(based on 310 CMR 15.203): NA Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): NA 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: NA t5ins•3/13 Title 5 Offibiel le90e066Feffn'SubS6Hke Sewage Disposal Sy§f'em:Page 7 of 17 Commonwealth of Massachusetts w W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 45 OLD PHINNEYS LANE Property Address SANTIAGO JOHN AND KELLY Owner Owner's Name information is required for every BARNSTABLE MA 02630 07/07/2016 page Cityrrown State Zip Code Date-of Inspection- D. System Information (cont.) Last date of occupancy/use: NA Date Other(describe below): NA General Information Pumping,Records: Source of information: NA Was system pumped as part of the inspection? ® Yes ❑ �No If yes, volume pumped: . NA gallons How was quantity pumped determined? NA Reason for p pum in 9� NA , 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 currentoperation and• maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 f Commonwealth of Massachusetts N W Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 45 OLD PHINNEYS LANE Property Address SANTIAGO JOHN AND KELLY Owner Owner's Name information is required for every BARNSTABLE MA 02630 07/07/2016 page. City/Town State Zip Gode Date=of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1996 Were sewage odors detected when arriving at the site? - ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: (1) ONE FOOT feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+ FEET feet Comments (on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK APPEARS TO BE STRUCTUARLLY SOUND AND FUNCTIONING PROPERLY'AT TIME OF INSPECTION. Septic Tank(locate on site plan): Depth below grade: (6) SIX INCHES feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) SEPTIC TANK APPEARS TO BE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY AT TIME OF INSPECTION. NA ' If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 GALLON Sludge depth: (1) ONE INCH t5ins-3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 45 OLD PHINNEYS LANE Property Address SANTIAGO JOHN AND KELLY Owner Owner's Name information is required for every BARNSTABLE MA 02630 07/07/2016 page. City/Town 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 (33)THIRTY THREE INCHES Scum thickness (1) INCHES Distance from top of scum to top of outlet tee or baffle (6) SIX INCHES Distance from bottom of scum to bottom of outlet tee or baffle 0 How were dimensions determined? MEASURED/VIEWED 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 APPEARS TO BE STRUCTUARLLY SOUND AND FUNCTIONING PROPERLY AT TIME OF INSPECTION . RECOMMEND PUMPING EVERY TWO YEARS. Grease Trap (locate on site plan): Depth below grade: NA feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): NA Dimensions: NA Scum thickness NA Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA Date of last pumping: NA Date 1505.3/13 TR16 5 MIN M9066ti6ei F&M.SU159uOR S€W298 DiS06W Sjif766•P396 10 6f'17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 45 OLD PHINNEYS LANE Property Address SANTIAGO JOHN AND KELLY Owner Owner's Name information is required for every BARNSTABLE MA 02630 07/07/2016 page. Cityfrown> State Zip Code Date=of•Inspection, D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): NA Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA Material of construction: r ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: NA Capacity: NA gallons Design Flow: NA gallons per day Alarm present: ❑ Yes ❑ No Alarm level: NA Alarm in working order: ❑ Yes ❑ No Date of last pumping: NA Date Comments (condition of alarm and float switches, etc.): NA *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection i - n Form 0 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 45 OLD PHINNEYS LANE Property Address SANTIAGO JOHN AND KELLY Owner Owner's Name information is required for every BARNSTABLE MA 02630 07/07/2016 page. Gityrrown 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 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.): DISTRIBUTION BOX APPEARS TO BE STRUCTUARLLY SOUND AND FUNCTIONING PROPERLY AT TIME OF INSPECTION Pump Chamber(locate on site plan): ry Pumps in working order: ❑ Yes ❑ No" Alarms in-working-order- ❑. Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): NA " 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: NA t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 45 OLD PHINNEYS LANE Property Address SANTIAGO JOHN AND KELLY Owner Owner's Name information is required for every BARNSTABLE MA 02630 07/07/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: NA ® leaching chambers number: (4) FOUR ❑ leaching galleries number: NA ❑ leaching trenches number, length: NA ❑ leaching fields number, dimensions: NA ❑ overflow cesspool number: NA ❑ innovative/alternative system Type/name of technology: NA Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): (4) FOUR INFLITRATORS APPEAR TO BE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY`AT TIME OF INSPECTION: APPROX. (3)`THREE INCHES OF PONDING WATER-AT TIME OF INSPECTION . HIGH WATER MARK APPROX(8) EIGHT INCHES. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA Depth—top of liquid to inlet invert NA Depth of solids layer NA Depth of scum layer NA Dimensions of cesspool NA Materials of construction NA Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M ,e' 45 OLD PHINNEYS LANE Property Address SANTIAGO JOHN AND KELLY Owner Owner's Name information is required for every BARNSTABLE MA 02630 07/07/2016 page. City/Town- 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.): NA Privy(locate on site plan): Materials of construction: NA Dimensions NA Depth of solids NA Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): NA t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 i Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 45 OLD PHINNEYS LANE Property Address SANTIAGO JOHN AND KELLY Owner Owner's Name information is required for every BARNSTABLE MA 02630 07/07/2016 page. Cityrrown 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 v>r. O 3 ' z I A2- At) j32 314 0 0 �"13 LU-5Z 4- S� V. Coq CV a 7 r Q OLD PHNNO L.M E t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection. Form- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 45 OLD PHINNEYS LANE Property Address SANTIAGO JOHN AND KELLY Owner Owner's Name information is required for every BARNSTABLE MA 02630 07/07/2016 page. City/Town State Zip Code Date of inspection. D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 10+FEET feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record . If checked, date of design plan reviewed: pate ❑ Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: ASBUILT ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: HAND AUGER Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page%of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 45 OLD PHINNEYS LANE Property Address SANTIAGO JOHN AND KELLY Owner Owner's Name information is required for every BARNSTABLE MA 02630 07/07/2016 page. CitylTown 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 15ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 r - Commonwealth of assachusetts . - . FTitle 5 Official Inspection Form _ - Subsurface Sewage Disposal System Form Not for Voluntary.Assessments 45 Old Phinneys Land Property Address:. William Swift Owner: Owner's Name information is required for every Barnstable Ma 02630 8-1-13 page: City/Town "State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any _.. way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, - use only the tab -1. Inspector: _. _. _ . .. key to move your cursor-do not . i use the return: Matthew Gilfoy. key. Name of Inspector B & B Excavation,lnc, r� Company Name 14 Teaberry Lane'' Company Address Forestdale MA: . _: 02644 ::: City/Town p State Zip Code 508-477-0653 S 113640 Telephone Number License.Number B. Certification 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 15000). The system: t. - Passes ❑ Conditionally Passes s ❑ Fail71 ❑ Needs Further Evaluationc� by the Local Approving:Authority . x- ca 8-1-13 Inspector's Signatur - Date k_ 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,7 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 Aescribes 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•11/10::: S Title 5 Official Inspec)i n or .ubsurface ewage:Disposal System.-:Page 1 of 17 ` \ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 45 Old Phinneys Land Property Address William Swift Owner Owner's Name information is required for every Barnstable Ma 02630 8-1-13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments °M 45 Old Phinneys Land Property Address William Swift Owner Owner's Name information is required for every Barnstable Ma 02630.. 8-1-13 page. City/Town State Zip Code - Date of Inspection B. Certification (cont.) 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): ❑ 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): f 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 n Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 45 Old Phinneys Land Property Address William Swift Owner Owner's Name information is required for every Barnstable Ma 02630 8-1-13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) I` 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: t ' **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 E ® 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 1 than / day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments' M 45 Old Phinneys Land Property Address William Swift Owner Owner's Name information is required for every Barnstable Ma 02630 . 8-1-13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the lastyear 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 1.00 feet of a surface water supply or ❑ ® tributary to a surface water supply. ❑ Z Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or-privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal,coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 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. 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 El ❑ 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 ZoneJI 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection f or n Subsurface Sewage Disposal System Form .- Not for Voluntary Assessments 'p 45 Old Phinneys Land Property Address:. William Swift Owner - Owner's Name - information is Barnstable Ma 02630 8-1_-13 required for every-. page. City/Town State Zip Code Date of Inspection C. Checklist - Check if the following.have been done:.You must i rid icate"yes"or"no':as to each.of the following: Yes No e El 1Z. Pumping information was provided by the owner, occupant, or Board of Health- Ej N 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 El_. ® this inspection? Were as built plans of thesystem:obtained and examined?(if they:were not ® available note as N/A)'. ® 0 Was the.facility or dwelling inspected for signs of sewage backup? 1Z ❑ Was the site inspected for signs of breakout? ® 0 Were all system components, excluding the SAS located on site?. ® El 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? 4. `Was the facility owner(and occupants if different from owner) provided with El ® 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: ® El 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 unacce table)[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: 11.0 gpd x#of bedrooms): .. 330 t5ins•11/10. Title 5 Official Inspection Form:Subsurface Sewage.pisposal System.•.Page 6 of 17: Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 45 Old Phinneys Land Property Address William Swift Owner Owner's Name information is Barnstable Ma 02630 8-1-13 required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes Z No Laundry system inspected? El Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): see below Detail: 2012-219 gpd 2013-238 gpd Sump pump? ❑ Yes ® No Last date of occupancy: July-1-2013Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 45 Old Phinneys Land Property Address William Swift Owner Owner's Name information is required for every Barnstable Ma 02630 8-1-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: {' .. Date � Other(describe below): ° General Information Pumping Records: Source of information: 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. El Other(describe): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 45 Old Phinneys Land Property Address William Swift Owner Owner's Name information is required for every Barnstable Ma 02630 8-1-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1996 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 1'10" Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: >20feet Comments(on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appeared to be in working order no sign of leakage or blockage. Septic Tank(locate on site plan): Depth below grade: 1 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: 1500 411 Sludge depth: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form , Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 45 Old Phinneys Land Property Address William Swift Owner Owner's Name information is required for every Barnstable Ma 02630 8-1-13 page. City/Town 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 32" 2" Scum thickness 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 151, How were dimensions determined? scour stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection septic tank appears to be structurally sound. No sign of back-up. Tank should be pumped for regular maintenance. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑,polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts , W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 45 Old Phinneys Land Property Address William Swift & Owner Owner's Name information is required for every Barnstable Ma 02630 8-1-13" page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): } Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes` ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 45 Old Phinneys Land Property Address William Swift Owner Owner's Name information is required for every Barnstable Ma 02630 8-1-13 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 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.): At time of inspection d-box appears to be in good condition. No signs of carry over or back-up. 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.): Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 45 Old Phinneys Land Property Address William Swift Owner Owner's Name information is required for every Barnstable Ma 02630 8-1-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4 infiltrators ❑ 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.): At time of inspection leaching in good working condition. No sign of hydraulic failure. Leach chambers were dry. System 11'X33'X2' i Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑, No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments o II M 45 Old PhinneY s Land Property Address William Swift Owner Owner's Name information is required for every Barnstable Ma. 02630 8-1-13 page. City/Town 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.): c I Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 I Commonwealth:of Massachusetts - Title 5 Offic-ial Inspection form -Subsurface Sewage:Disposal System Form - Not for Voluntary Assessments 45 OId:Phnlieys-Land Property Address :William Swift Owner Owner.s'Name information is required for every Barnstable Ma 02630 8-1-1.3.page. .Cityrrown 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 _ 6 A3- 3i 6 3 �q - qo' e)z-.u W 63 b3 bq t5ins•11H0 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 45 Old Phinneys Land Property Address William Swift Owner Owner's Name information is required for every Barnstable Ma 02630 8-1-13 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar Y ' ® Shallow wells Estimated depth to high ground water: no gw @ 25' 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: usgs topo maps You must describe how you established the high ground water elevation: topo maps Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Plod Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 45 Old Phinneys Land Property Address William Swift Owner Owner's Name information is Barnstable Ma 02630 8-1-13 required for every ' page. City/Town 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 9.,/ PARCEL N6 BORTOLOTTI CONSTRUCTION,INC. 765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 "� 'v<<q.* 508-771-9399 508-428-892G . FAX: 508-428 9399 V � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PA RT A CERTIFICATION Property Address: Date of Inspection: Inspec o 's Nam : y Ow er's Name a d Address: _CERTIFICATION STAT M NT• I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of inspection. The inspection was per- formed based on my training and experience in the proper,runction and maintenance of on-site sewage disposal systems. The System: Passes Conditionally Passes ' Needs Further Ev luation th Local Aproving Authority. Fails Inspector's Signature: fate: The System Inspector shall submit a copy of thus inspection report to the Approving authority within thir- ty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTIONS M ARY• A)SYSTEM PASSES: 1 have not found any in formation which indicates that the sysicnn violates any of the failure ' criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system, upon comple- tion of the replacement or repair, passes inspection. Indicate yes,nor,or not determined(Y,N,OR ND). Describe basis of determination in all instances. If not determned",explain why not. The septic tank is metal,cracked,structurally unsound, shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of The Board of Health): SUBSURFACE SEWAGE DISPOSAL SVSTFM INSPECTION FORM PART A CERTIFICATION (continued) Broken pipe(s)replaced Obstruction is removed Distribution Box is levelled or replaced The System required pumping more than four.times a year due to broken or obstructed pihe(s). Board of Hea Ith . if with approval of'The Boy )' The system will pass inspection ( pp Broken pipe(s)are replaced Obstruction is removed 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 t ons eq the system is failing to protect the public health, safety and the environment. 1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND TILE 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 HEALTiI (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECT THE PUBLIC HEALTi1 AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 Feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is with a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 Feet but 50 Feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from the facility and the presence of ammonia nitrogen and ui(rat.e nitrogen is equal to or less than 5 ppm. D)S STEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. ekup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. rS tic liquid level in the distribution box above outlet invert due to an overloaded or clog- ged SAS or cesspool. Liquid depth in cesspool is less thau G"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the lass.year hLS2T due to clogged or obstructed pipe(s). Number of times pumped -2- . 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PA RT A CERTIFICATION (continued) Any portion of the Soil Absorption Systcm, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 Feet of a surface water s►,ipply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I 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 duality analysis. if the well has been analyzed to be.acceptable,attach copy of well water analysis for coli.l'orm bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: The system is within 400 Feet of a surface drinking water supply The system is within 200 Feet of a tributary to a surface drinking water supply The system is located in a nitrogen sensitive area Interim Wellhead Protection Area (IWPA)or a mapped Zone 11 of a public.water supply well. The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: Pumping information was requested of the owner,occupant, and Board of Health. _None of the system components have been pun►ped for aticast.two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. V/As-built plans have been obtained and examined. Note if they are notavailabhe with N/A. I/Tlre facility or dwelling was inspected for signs of sewage back-up. t/The system does not receive non-sanitary or industrial waste flow. ✓The site was inspected for signs of breakout. ' /All system components,excluding the Soil Absorption System, have been located on site. •jhe septic tank manholes were uncovered, opened,and the interior of the septic tank was in- spected for condition of baffles or tees, material of construction,dimensions,depth of liquid, Slepth of sludge,depth of scum. . The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive tnelhods. -3- '. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART 11 CIIECKLIST(continued) Y . n re provided with information on The facility owner(and occupants, if dnllereut from owner) w 1 c c the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSI'ECT'ION FORM PART C SYSTEM.INFORMATION FLAW CONDITIONS RF.SI_DENTIAI.: v Design Flow: gallons Number of Bedroorns:__a Nnnnb r of Current Residents: 1� Garbage Grinder.AE Laundry Connected To System: O Seasonal Use: Water Meter Readings, if ailable: Last Date of Occupancy: COMM F.RC AL/INDL ST'RIAL•A/0 Type of Establishment: Design Flow: gallons/day Grease.Trap Present• (ycs or no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V Syste�ii: Water Meter Readings,If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS and source of inforrna ' w--i0o��1_ ._ vh. _ I 6 of ection: volume pun ed. allons System Pumped as part o sp II es y I P g Reason for pumping: TYPE OF SYSTEM: Septic Tank/Distribution Box/Soil Absorption Systen Single Cesspool Overflow Cesspool Privy red System(If yes,atl h previous ii pection records, if any) Other(explain) APPgOXIMATE AGE of all components, date insMel if known)and source of information: �p slei Sewage odors detec ed when arriving at.the srlc:_-IVA_ -4- SUBSURFACE SEWAGE UI:SPOSAI.,SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continiied) SEPTIC TANK: Depth below grade: Material of Construction: concrete ---metal FRP Other (explain) _ — Dimisions:' Sludge Depth: _Scum Thickness: Distance from top of sludge to bottom of outlet tee or baffle:_ Distance from bottom of scum to.bottom of outlet tee or battle:_ _ Comments: (recommendation for pumping,condition of inlet and outlet lees or baffles,depth of liquid level in relation to outlet invert, structural integrity,evidence of leakage, etc..)_ GREASE TRAP: Depth Below Grade. Material of Construction: concrete .-- iiietal FRP Other (explain) -- -- -- -- Dimensions: - --Scum Thickness.-- - - - -- Distance from top of scum to top of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees of baffles,depth of liquid level in relation to outlet invert, structural integrity,evidence of leakage,etc.) TIGHT OR HOLllING'I'ANK:L��Sl ---- -- ' Depth Below Grade: Material of Construction:-_ concrel.c_iuctal FRP Otlier(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm Level: Comments: (condition of inlet tee,condition of alarm and floal switches,etc.)= llISTR1BUTION BOX:-��� ----------- Depth of liquid level above outlet invert: Comments:'(note if level and distribution is equal, evidence of solids carryover evidence of leakage into or out of box,etc.) .PUMP CHAMBER:�L��J — - ------------ Pump is in working order; Comments: (note condition of pump chamber,condition of pumps and appurtenances;etc.) -5 % v SUBSURFACEBEWAGE.UIS1'OSAL S1'S'1'I�;M INSPECTION FORM PART C SYSTEM INFORMATION (conlinued) SOIL ABSORPTION SYSTEM (SAS): /0 (Locate on site plan, if possible;excavation not required, but naay be apliroxintated by non-intn►sive methods) If not determined to be present, explain:____________-____ Type: Leaching pits,number: Leaching chambers, L,eaching galleres,nun�bcr: Leaching trenches,number, length: Leaching fields,.number,dimensions: Overflow cesspool,number: Comments: (note condition of soil, signs of hydraulic failure level of pon(jing, condition of vegetation, etc.) CESSPOOLS: v Number and configuration: Deptli-top of liquid to inlet invert: Depth of solids layer: Depth of scuni layer:_ Dimensions of Cesspool: Materials of construction: Indication of groundwater`. Inflow(cesspool must be pumped as part of inspection)_ _ Comn opts: (note con ition of soilk, signs of h draulic Failure, level of onditig,condition of vegetation, / �� � etc.) - - _ �(.�. _�1^i' � PRIVY: ------------ . _.. Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) -- _.------ -..:_:--- -- -- — -6 - SUBSURFACE SEWAGE DISPOSAL.,SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(coiilinued) SKETCH OF SEWAGE DISPOSAL,SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within.100 Feet. ( DEPTH TO GROUNDWATER: Depth to groundwater: Z feet Method of Determination or Approximation:_A /'�,,(�/t�j� -can -7- TOWN OF BARNSTABLE l� LOCATION X° e-VeY& Xa, SEWAGE # fU pLlyl7 VILLAGE_. C f S R*,,14�ASSESSOR'S MAP &LOT Z 71 INSTALLER'S NAME&PHONE NO. 7LO,09j 45�P —CV.-- 7 7/" SEPTIC TANK CAPACITY 1�VO GAL K' ry LEACHING FACILITY: (type)--Ev,�, L t'C A+ar S (size) 3 W NO. OF BEDROOMS _ BUILDER OR OWNER PERMITDATE: 7 `� 7 ' COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 Furiushed by s w b c v-s Gel � a E 4 TOWN OF BARNSTABLE LOCATION /b SEWAGE # VELLAGE �ASSSE R'S_/MAP& LOT 0S1�.S NAME&PHONE NO. r '�'f O V SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BED BUILDER OWNER /, 1. PERMTTDATE: COMPLIANCE DATE: Separation Distance.Between the: Maximum Adjusted Groundwater Table and 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 fac ) Feet ility Furnished by Fee THE COMMONWEALTH OF MA ACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0[ppYication for Miopo5ar *pgtem Construction Permit Application is hereby made for a Permit to Construct( )or Repair(✓)an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. qr ®/P � mne-ls i�, erg Assessor's Map/Parcel ` ' Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. zz Type of Building: Dwelling No.of Bedrooms .3 Garbage Grinder( � Other Type of Building 5 e Ge No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 330 gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature f Repai or Alterations(Answer when applicable) 4, - 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 Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by is o of r F Signed Date Application Approved by ,© Date Application Disapproved for the following reasons Permit No.. '� Date Issued Z&L l Yee` �1Vo`.r.: n ,V r .. Fee t THE COMMONWEALTH OF MA ACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASdACHUSETTS Otpprication for Xi5pozat bpgtem Construction Permit Application is hereby made for a Permit to Construct( )or Repair(tan On-site Sewage Disposal System at: Location Address or Lot.No. t Owner's Name,Address and Tel.No.y� 1 6r�e/i, �a rG Assessor's Map/Parcel: Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. - 3 Type of Building: Dwelling No.of Bedrooms fiarbage Grinder( !� Other Type of Building %?4i,, e No.of Persons Showers( ) Cafeteria(. ) Other Fixtures Design Flow //12 gallons per day. Calculated daily flow 330 gallons. Plan Date Numbei of sheets Revision Date Title Description of Soil f: i Nature of Repairs or Alterations(Answer when applicable) zh'.'51t7/1 /.S �11�)94` tD.9�l ` ���664Z GnZi/ � /l ty X 33 L ,�1 7 '.✓J 1/6 is 4/ 2-242 'f 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 Environmental Code and not to place the system in operation until a Certifi cate of Compliance has been issued by Ops Board of H a th. Signed Date T Application Approved by ! _ Date Application Disapproved fo the following reasons i i Permit No. 64 Date Issued M.6 —————————————————.———..———————— THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS _ G Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced( on ` by Installer �r tr�LaJf�% GOryS>` at y S /,9,112 al d4P�l< has been constructed.in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated t Date Inspector ) `'•� THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS'A GUARANTEE THAT THE SYS- TEM WILL FUNCTION SATISFACTORY. No.L,/! .,►--:——.---'--------------- 2_ 7f.� G-3. Fee__ THE COMMONWEALTH OF MASSACHUSETTS ' PUBLIC HEALTH DIVISION -�BARNSTABLE, MASSACHUSETTS a 33ioo.5al 6pgtem Construction Permit Permission is hereby granted -o to construct( . )repair( n On-site Sewage System located at No.# t Sveet' J ` and as described in the above Application for Disposal System Construction Permit. "' 1 . No. ' Da e The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or sp cial Condit� .s. r All construction must a com, e ed:within three years of the date below. Date: Approved by B 1 ( Board of Heal r CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION I'EIt51CT (1VITHOUT DESIGNED PLANSI I, ®�� ' ;j Jel�A/& hereby certify,that the application.for.disposal works construction permit signed b me dated lel concerning the p B Y located at y ©�� ��� S �%. ��d/5 meets all of the property , following criteria: V/Thcre are no wetlands within 300 fcct'of(lie r sed SePilc system P � I /There arc no private wells within i5o fcc!of the proposed septic system vlThe observed groundwater table is I rcc! or 2reaicr below the bottom or the leaching facility here is no increase in low and/or chan¢ein use proposed There are no variances rcgnesied or needed. SIGNED : %A� DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER (Attach a sketch plan of the proposed system. Also if the licensed Installer posesses a certified plot plan, this plan should be submitted]. 0*0WW .. ...•....+ CIO 'SO pop !D ti VIC LDLD `S C� 0 02�PQ� j�d �t��n� �-- �GJ�•loG� � y 6L6 ptfiNrJ _1 • `ii