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HomeMy WebLinkAbout0067 OLD PHINNEY'S LANE - Health '67 Old Phinney's Lane Barnstable, P - Y` A 276026 c 6 t$, '{ Commonwealth of Massachusetts. .. _ F _Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments �M 67 Old Phinney's Lane .. Property Address. .... Edward Poirier Owner Owner's Name information is required for every Barnstable MA 02630 12/31/12 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 A. General Information filling out forms . on the computer; .3 use only the tab 1. Inspector: .. ...... key to move your cursor-do not... Ricky Wright use the return: key. Name of Inspector B & B Excavation-Inc. Company Name 14 Teaberry Lane x.. Company Address Forestdale .. MA;:. 02644 City/Town State Zip Code 508-477-0653 S14595 Telephone Number License.Number B. Certification x certify that I have personally inspected the sewage disposal system at this address and that the c 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 onsite sewage disposal systems. I am .a:DEP approved system inspector pursuant to Oection 1340 of Title 5(310 CMR 15.000). The:system: . .. CD ` • ® Passes.- ❑ Conditionally Passes ❑ .Fails Needs Further Evaluation by the Local`:ApprovingAuthority i 12/31/12 Ins ctor's Tigna� - Date The system inspector shall submit a_copy of this inspection report to the Approving Authority(Board of Health or:DEP)within 30 days of completing this inspection. If the system is a shared system or has a design.flow of 10,000 gpd or greater, the inspector and the.system owner shall submit the. report to the appropriate regional office of the DEP. The original should be sent to the system owner _. and copies sent to the buyer, if applicable, and the approving:authority. ****This report only describes conditions at the time.of inspection and under the conditions of use at that time.This inspection does.not address how.the system will perform in the future under the same or different conditions:of use. t5ins•11/10 Title 5 Official Inspectio o :Subsurface Sewage:Disposal System:•:Pagel of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 67 Old Phinney's Lane Property Address Edward Poirier Owner Owner's Name information is required for every Barnstable MA 02630 12/31/12 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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 L v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Old Phinney's Lane Property Address Edward Poirier Owner Owner's Name information is required for every Barnstable MA 02630 12/31/12 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): 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1M , 67 Old Phinney's Lane Property Address Edward Poirier Owner Owner's Name information is required for every Barnstable MA 02630 12/31/12 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: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® 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 Y 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 o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 67 Old Phinney's Lane Property Address Edward Poirier Owner Owner's Name information is required for every Barnstable MA 02630 12/31/12 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. El . ® 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 ❑ ❑ 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17' Commonwealth of Massachusetts Title 5 Official Inspec ion Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 67 Old Phinney's Lane Property Address:. Edward Poirier Owner Owner's Name .. information is required for Barnstable MA 02630 12/31/12 every page: Clty/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 ❑ M Were:any of thasystem 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? . _. Wem:as built-plans of theaystem.obtained arid: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? El ® 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 of the Board of Health. I ® 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)::: 2 Number of bedrooms(actual):: 2 .DESIGN flow based.on 310 CMR 15.203.(for example: 110 gpd x#of bedrooms); 220 t5ins•1-1/10:: Title 5 Official Inspection Form:Subsurface Sewage:Disposal System-:Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 5 67 Old Phinney's Lane Property Address Edward Poirier Owner Owner's Name information is required for every Barnstable MA 02630 12/31/12 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: , 2011 = 148 gpd 2012 = 214 gpd Sump pump? ❑ Yes ® No Last date of occupancy: current Date 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 i Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Old Phinney's Lane Property Address Edward Poirier Owner Owner's Name , information is required for every Barnstable MA 02630 12/31/12 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 Y ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 67 Old Phinney's Lane Property Address Edward Poirier Owner Owner's Name information is required for every Barnstable MA 02630 12/31/12 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): I 15" ' Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): _ Distance from private water supply well or suction line: >10feet 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): Y 7�� Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ® No Dimensions: 1000 gal Sludge depth: V. 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 ;M 67 Old Phinney's Lane Property Address Edward Poirier Owner Owner's Name information is required for every Barnstable MA 02630 12/31/12 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 36" Scum thickness 1/2 811 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 14" 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. 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 ^M 67 Old Phinney's Lane Property Address Edward Poirier Owner Owner's Name information is required for every Barnstable MA 02630 12/31/12 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): I 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 67 Old Phinney's Lane Property Address Edward Poirier Owner Owner's Name information is required for every Barnstable MA 02630 12/31/12 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.): 4 At time of inspection d-box appears to be in good condition. 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: l5ins•11/10 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 °M 67 Old Phinney's Lane Property Address Edward Poirier Owner Owner's Name information is required for every Barnstable MA 02630 12/31/12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At time of inspection leaching appears to be in working condition. No sign of hydraulic failure 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Old Phinney's Lane Property Address Edward Poirier Owner Owner's Name information is Barnstable MA 02630 12/31/12 required for every 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.): 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 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System foam -Not for Voluntary Assessments M 67 Old Phinney's Lane Property Address Edward Poirier Owner Owner's Name information i required for, Barnstable MA 02630 12/31/12 :every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate: where public water supply enters the building. Check one of the boxes.below: ® hand-sketch in the area below ❑ drawing attached separately L:�j ` �a. j Al 0 .1 r . - 3ii.t AH 941 2 - Lo ` 3 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page,15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM 67 Old Phinney's Lane - Property Address Edward Poirier Owner Owner's Name information is required for every Barnstable MA 02630 12/31/12 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: 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: ma.water.usgs.gov You must describe how you established the high ground water elevation: . w property elevation = 92.41 slope to west of property drops to elev 58.23 No groundwater in slope Before filing this Inspection Report, please see Report Completeness Checklist on next page. . (Sins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 l Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM , 67 Old Phinney's Lane Property Address Edward Poirier Owner Owner's Name information is required for every Barnstable MA 02630 12/31/12 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 TOWN OF BARNSTABLE LOCATION �'� ®, °� v���f„� SEWAGE# VILLAGE. ASSESSOR'S MAP&PARCEL ` <=>g.G INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY C > LEACHING FACILITY:(type) L.-4G� Q� (size) NO. OF BEDROOMS rro� OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY Ld v► U s � � op tx i r Commonwealth of Massachusetts 4 ` Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Old Phinney's Lane Property Address Philip Lynch Owner Owner's Name 1 information is Barnstable MA 02630 required for February 20, 2009 every 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. Impor tant:W filli When filling out A. General Information W forms on the computer, use 1. Inspector: SI3 only the tab key , 51, to move your Patrick T. Sullivan cursor-do not Name of Inspector use the return key. Ready Rooter, Inc. Company Name PO Box 371 -17 Jan Sebastian Dr. Company Address Sandwich MA 02563 City/Town State Zip Code 508-888-2805 S112843 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority t �'L February 27, 2009,: Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. i ****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. f 67oldphinneysta 03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 1 _ l 1 � Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I wM 67 Old Phinney's Lane Property Address Philip Lynch Owner Owner's Name information is required for Barnstable MA 02630 February 20, 2009 every page. CityTrown 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 ® 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: i 1 i 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,,6f 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. r f ElThe 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 thgq xisting 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 indicatip�that the tank is less than 20 years old, is available. ND Explain: I j ❑ Observation of sewage backup or break out or hig static water level in the distribution box due to broken or obstructed pipe(s) or due to a broln, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): i ❑ broken pipe(s) are replaced ❑ obstruction is removed 67oldphinneysla-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 2 f Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 Old Phinney's Lane Property Address Philip Lynch Owner Owner's Name information is Barnstable MA 02630 February 20 2009 required for ry every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or re faced 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): ❑ brokZction ripe(s) are replaced ❑ obstr is removed ND Explain: 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. J., 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: f F ElCesspool or privy is within 50 feet of t 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: t- ❑ 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/6 septic tank and SAS and the SAS is within a Zone 1 of a public water supply. �r ❑ The systerryhas a septic tank and SAS and the SAS is within 50 feet of a private water supply weN. 67oldphinneysla•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 3 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Old Phinney's Lane Property Address Philip Lynch 4 Owner Owner's Name information is Barnstable MA 02630 February required for 20, 2009 every page. City/Town State Zip Code t Date of Inspection B. Certification (cont.) 1 C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is I 's 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 indicates absent and the presence,'i 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. f' i 3. Other: k 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 town 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 i r ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow I ❑ ® 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. } 67oldphinneysla•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 4 e i ` Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Old Phinney's Lane Property Address Philip Lynch Owner Owner's Name information is ry Barnstable MA 02630 February 20 2009 required for , every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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" oX{"'ono`"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 4,4)0 feet of a surface drinking water supply �J ❑ ❑ the system is wit 4in 200 feet of a.tributary to a surface.drinking water supply ElEl the system is ocated in a nitrogen sensitive area (Interim Wellhead Protection Area—IWP ")or a mapped Zone II of a public water supply well If you have answered "yes"to ny question in Section E the system is considered a significant threat, or answered "yes" in Sectio D above the large system has failed. The owner or operator of any large system considered a sign' cant threat under Section E or failed under Section D shall upgrade the system in accordance s h 310 CMR 15.304. The system owner should contact the appropriate regional office of the partment. 67oldphinneysla•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 Old Phinney's Lane Property Address Philip Lynch Owner Owner's Name information is Barnstable MA 02630 February 20 2009 required for ry every page. City/Town State Zip Code Date of Inspection ,C , I C. Checklist fi Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ' fi ® ❑ 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? i The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] i I I i 67oldphinneysla-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Old Phinney's Lane. Property Address Philip Lynch Owner Owner's Name - information is Barnstable MA 02630 February 20 2009 required for ry every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 GPD Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usa e 2007= 112 GPD 9 ( Y 9 (gpd)) 2008= 156 GPD Sump pump? El Yes ® No Last date of occupancy: Current Date 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.): i Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? y. ❑ Yes ❑ No Non-sanitary waste discharged to the Tittle 5 system? r ❑ Yes ❑ No Water meter readings, if available: 1 Last date of occupancy/use: Date Other(describe): r 1' p . 67oldphinneysla•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 7 Commonwealth of Massachusetts x W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 67 Old Phinney's Lane Property Address Philip Lynch Owner Owner's Name information is Barnstable MA 02630 1 February 20 2009 required for rY every page. City/Town State Zip Code Date of Inspection l D. System Information (cont.) General Information Pumping Records: Source of information: Ready Rooter records: Pumped Nov. 2008 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 El I Single cesspool 1 ❑ Overflow cesspool I ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) j ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): I Approximate age of all components, date installed (if known) and source of information: System 10+ years old. Previous Title V Inspection 2005. On-line records. Were sewage odors detected when arriving at the site? ❑ Yes ® No 67oldphinneysla•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments . 67 Old Phinney's Lane Property Address Philip Lynch Owner Owner's Name information is ry Barnstable MA 02630 February 20 2009 required for , every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 115„feet; Material of construction: ❑ cast iron ® 40,PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 711 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: 8 X 4.5 X 4.5 1000 Gals Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 36 Scum thickness 1/2" 8„ Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 1411 How were dimensions determined? Tape measure and dip tube. 67oldphinneysla•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 9 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Old PhinneYs La ne Property Address Philip Lynch Owner Owner's Name information is required for Barnstable MA 02630 February 20, 2009 every page. Cityrrown State Zip Code Date of Inspection i D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee o i r baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet concrete baffles in place. Very little solids. Liquid level at outlet invert. i Grease Trap (locate on site plan): Depth below grade: .. feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): rY I Dimensions: r s Scum thickness Distance from top of scu,lortop of outlet tee or baffle Distance from bottom"of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee orlbaffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): i ?i 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): i 67oldphinneysla•03/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 10 of 10 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM '( 67 Old Phinney's Lane Property Address Philip Lynch Owner Owner's Name information is required for Barnstable MA 02630 February 20, 2009 every page. City/Town State Zip Code } Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: �allons per day i Alarm present: f. f❑ Yes ❑ No Alarm level: , :Alarm in working order: ❑ Yes ❑ No Date of last pumping: ,/ Date Comments (condition of alarm an float switches, etc.): ++ E x Ste. *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): i OilDepth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): One inlet, one outlet. No solids carryover. Liquid level at outlet invert. No sign-of high water staining over outlet invet. Cover within 1'of grade. l Pump Chamber,(locate on site plan): I Pumps in working order: ❑ Yes ❑ No Alarms in working order: �t, ❑ Yes ❑ No I 1. 67oldphinneysla•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 Old Phinney's Lane Property Address Philip Lynch Owner Owner's Name information is Barnstable MA 02630 February 20, 2009 required for ry every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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: Type: ® leaching pits number: 1-6X6 w/4' stone ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Liquid level 4' below invert at time of inspection. High water.staining at 3'6" below invert. No sign of past hydraulic failure. Cover within 1' of grade. 67oldphinneysla-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Old Phinney's Lane Property Address Philip Lynch Owner Owner's Name information is ry Barnstable MA 02630 February 20 2009 required for , every page. Citylfown State Zip.Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert a Depth of solids layer E Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater in9ow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): . Materials of construction: Dimensions P Depth of solids " Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): s 67oldphinneysla•03/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 13 7 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 67 Old Phinney's Lane Property Address Philip Lynch Owner Owner's Name information is Barnstable MA 02630 February 20 2009 required for ry every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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. O O r� A A Q c Qgvl 1 I � 67oldphinneysla•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 14 Commonwealth of Massachusetts u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments . i M 67 Old Phinney's Lane Property Address w Philip Lynch Owner Owner's Name information is Barnstable MA 02630 February 20, 2009 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.)' Site Exam: ® Check Slope ❑ Surface water ❑ Check cellar El Shallow wells Estimated depth to high ground water: >5 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: a pate ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Previous Title V inspection'(2005) ❑ Checked with local excavators; installers-(attach documentation) g, ® Accessed USGS database-explain:,,' ma water.usgs.gov terraserver-usa.com town.barnstable.ma.us You must describe how you established the high groundwater elevation: Property EIv= 92.41, slope to west of property drops to EIv= 59.23�No breakout of ground water in slope. Accessed local ground water contour and topo mapping. High ground water at approx. 30'. a 67oldphinneysla•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 � CP COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION F TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 6 7 /9/d � '(� Owner's Name: A ji'�on -Io.n e-5 S08- C) Owner's Address:' e cald Af#?!e9r,S Ane w_ AM-3�A 7 Date of Inspection: y 1YI65 aft Name of Inspector please print) /rrloA y A- Lyle- N 1 A ,to Company Name: rO IP X t661 P. Mailing Address: /I I yT_y bdw.)+4 , A09 OZ,3GZ N 3> Telephone Number: 2?y- `1 fy-9o2 7 2 ram•" 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 Signatu t Date:' y-,/a 5 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments s�sfem �,?sse5 41 /,gee ,I ****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: 67 D/b/ /�h�4/7e+i3 fn-k- Owner• Atinon �(o Date of Inspection: c26__ 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: 0jOne or more system components as described in the"Conditional Pass"section need to be replaced or paired.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 structed 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 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 s 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: 6 7 a/cf 14 4,de%S LA",�e $Rrns-1Rhlti�ina/1 Owner: dfi.x>-, .Jo.w S Date of Inspection: `L N-oS C. Further Evaluation is Required by the Board of Health: 4.` . Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System 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 i 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: 40 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 eoliform 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: Title 5 Inspection Form 6/15/2000 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Old l-rn s 11e- +Abl!e s Owner: 41130 n 4,M r.S Date of Inspection: • 11-N-ed5 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No k Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Y 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 X Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow - Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. i' 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 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.] (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. E. Large Systems: 1V11q To be considered a large system the system most serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone H of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Title 5 Inspection Form 6/15/2000 I kge5of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 6 Z O&/" millf,Y Owner:A/i,S. i J6 n r S Date of Inspection:hs-NW Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No Y _ Pumping information was provided by th owner occupant,or Board of Health _ Were any of the system components pumped out in the previous two weeks? J( 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? 4AM Were as built plans of the system obtained and examined?(If they were not available note as N/A) _ Was the facility or dwelling inspected for signs of sewage back up? _ Was the site inspected for signs of break out? — Were all system components,excluding the SAS,located on site? _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _ _ Existing information.For example,a plan at the Board of Health. 4 _ Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Title 5 Inspection Form 6/15/2000 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: l PR111A f Y A-d Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Z Number of bedrooms(actual): 7_ DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Z Zo Number of current residents: / Does residence have a garbage grinder(yes or no):o!!�V Is laundry on a separate sewage system(yes or no):� [if yes separate inspection required] Laundry system inspected(yes or no):i&5 Seasonal use:(yes or no):A Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no):AA Last date of occupancy: esr/dn� COMMERCIAL/INDUSTRIA JX Type of establishment: Design flow(based on 310 CMR 15.203): apd 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: �,?!�//L•e/ Was system pumped as part of the inspection(yes or no): If yes,volume pumped: A lions--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach axopy of the DEP approval Other(describe); Approximate age of all components,date installed(if known)and source of information: 4in(cnow A/o Re-ords A+ B o ii, Were sewage odors detected when arriving at the site(yes or no):A/ Title 5 Inspection Form 6/15/2000 6 f Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 67 O/d P/Pr/rt2�V'f AA e— Owner: ,41r' ,, -&Ve Date of Inspection: y-N os BUILDING SEWER(locate on site plan) Depth below grade: A/5, Materials of construction:_cast iron 1K-40 PVC_other(explain): Distance from private water supply well or suction line: „0' Comments(on condition of joints,venting,evidence of leakage,etc.): /t/O Agyrdl,Enr.le OP, llt�/ Veln4ltt Link CAA- %w.c aX:THSe-+l. ,,,., SEPTIC TANK:-X-(locate on site plan) Depth below grade: Material of construction:I'concrete metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: /L29O 6,4-//c 7s Sludge depth: �1'N Distance from top of sludge to bottom of outlet tee or baffle IJ5 b Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle:,,—d Distance from bottom of scum to bottom of outlet tee or baffle: J,?` How were dimensions determined: 24 e Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): �S'e rn nt�d �v /Ji�y �i/t2✓�/ 9 YW3 !e sn l'crxd 1 6 itJ&'&:v,dg-Ac.r e,4 LeAketf-t GREASE TRAP:410cate on site plan) Depth below grade: Material of construction:concrete metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: •Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity;liquid levels as related to outlet invert,evidence of leakage,etc.): Title 5 Inspection Form 6/15/2000 7 i Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM/ INFORMATION(continued) Property Address: 4 7 n/cl Dkinnys b.AA 014r"SVsWV-a MA Owner: A li'so i Jon*S Date of Inspection: -*+05 TIGHT or HOLDING TANK:N*(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:-4� (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Continents(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.): /l/U 1�101eAGtL Of /t d 06ne4 o �i A5V Wt-LCj9 vim. L,c L,�✓ /re`te s� PUMP CHAMBER-��(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.): 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: b 7 4>/d AlilAf Y /:�v4rnStrrt 1*e / a Owner: A t 5 Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number. leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): /.4 U,d kf Ad /' 1 4-1.0.J I M~ 3' 7 15't64 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.): 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.): 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: A 7 p/al/toed/,an,( Owner:A 11*5-A -1,,AA.3 Date of Inspection: q—y o f SKETCH OF SEWAGE DISPOSAL SYSTEM 1 Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or Q` benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. 33�q1 /-3AL12 6� tjve-,L 3YSa \ lq� t I . 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: 67 01d Ai nsiabN, M,? Owner:f kSon jin*S Date of Inspection: �I_q 5 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water y5 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 most describe how you established the high ground water elevation: Title 5 Inspection Form 6/15/2000 11