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HomeMy WebLinkAbout0201 SCUDDER'S LANE - Health 201 Scudder Lane Barnstable A= 259-005 0 I TOWN OF BARNSTABLE LOCATION S L(J J J" SEWAGE S �� VILLAGES > > ASSESSOR'S MAP & LOT o 6 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY s LEACHING FACILITY:(type) (size) NO.OF BEDROOMS BUILDER OR OWNER . ^°o y Q PERMITDATE: 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 Furnished by �; 1.-� � ^�► S ���( yB ✓'v ice.4 i S) - Jf r i 400A4 Commonwealth of Massachusetts Title 5 Official Inspection Form `s! Subsurface Sewage Disposal System Form-Not for.Voluntary Assessments „N 201 Scudder Lane , Property Address ., s Suzi Newman . Owner Owner's Name information is required for every Barnstable MA. 02630 12/10/13 page. City/Town State w Zip Code,' Date of Inspection. Inspection results must be submitted on this form.inspection forms may not be aftered in any way.Please see completeness checklist at the end of the form. Important:When A. General Information' filling out forms on the computer, use only the tab 1. Inspector: ` key to move your cursor-do not ajlYl a Kevin Cochran , use the return _ key. Name of Inspector _a y Aardvark Environmental InspectionsVQ Company Name ` PO Box 896 - ,z Company Address ; East Dennis MA = J2641 - ' Cityrrown NJ State ip Code t" 508-385-7608 SI13356' Telephone Number - License Number B. Certification I certify that 1 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 Evaluati by the Local Approving Authority .12/15/13 Inspecto5gratgnature Date The system inspector shallsubmita 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 f has a design flow of 10,000 god or greater,the inspector and the system owner shall submit the report to the appropriate,regional office of the DEP.The original should lie 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'underthe 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 11/1 0�`•. '" " 4 .f + Trtfe 5 offtci In etion Form:Subsurface Sewage Disposal System•Page 1 of 17 P Commonwealth of Massachusetts f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 201 Scudder Lane ' Property Address Suzi Newman Owner Owner's Name information is required for every Barnstable MA 02630 12/10/13 , - • page. Cltylrown 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: i Y B) 'System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"-section need to be 4 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)'forthe 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 E El°ND (Explain below): t5ins•11/10 - Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17 4 a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 201 Scudder Lane Property Address Suzi Newman "r. Owner Owner's Name K.�. information is required for every Barnstable MA 02630 12/10/13 ' page. City/Town State Zip Code ;' Date of Inspection B. Certification (cont.) �. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup orbreakout 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):P ❑ 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 removedY ❑'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`6nvironment. 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 mannerwhich 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 f5ins•i f/tQ Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts" : Y + Title a Officiallnspection Fora s Subsurface Sewage Disposal System Form Not for Voluntary Assessments re 201 Scudder Lane r t Property Address - Suzi Newman k . Owner Owner's Name information is required for every Bamstable ~ 'a MA 02630 12/10/13 • page. City/Town State. Zip Code Date of inspection B. Certification (cost:) a 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, tsafety and environment.,:., w .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. 4 , ❑ The system has a septic tank and SAS and the SAS'is within 50 feet ofa pnvate 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. x 3. Other: D)'System Failure Criteria Applicable to All Systems.'` ';You must indicate"-Yes"or`.`No"to each of the foltowing for all inspections: ti Yes . No Backup of sewage into facility or stem component due to overloaded`or • p 9 h+: Y p - ® clogged SAS or cesspool / Discharge or ponding of effluent to the surface of the ground or surface.waters. . . - } ❑ ® ' due to an.overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded ❑: ® or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less '❑ , than day flow • t5ins-11/10. - ♦ - '"• Title 5Official Inspection Forms Subsurface Sewage Disposal System-Page 4 of 17. r Commonwealth of Massachusetts Title 5 Official, Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 201 Scudder Lane Property Address Suzi Newman Owner Owner's Name information is Barnstable {" MA02630 , 12/10/13 required for every - ,. page. Cltylrown State� Zip Code ;" Date of Inspection B. Certification (contsj ; Yes No Required pumping more than 4 times in the last year NOT due to clogged or. El 0 obstructed pipe(s).Number of times pumped: ❑ ® Any portion of the SAS,cesspool or privy is below.high groundwater elevation. Any portion of cesspool or privy is within 100 feet of a`surface water,supply or v_ tributary to a surface water supply. ❑ ®,. Any portion of a cesspool or privy is within a Zone 1'of a public well.` t • ❑ ® 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• p pply p 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.. R s For large systems,you must indicate-either"yes"or"no"to each of'the following,in addition to the questions in Section D. ' A r Yes No s x ❑ the system is within 400 feet of a surface drinking'water supply El ❑- 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 ProtectionEl ' ❑ Area—IWPA. ° )or a mapped Zone II of a public water supply well - If you have answered "yes"to anyquestion in Section Ethe`system is considered a significant threat, or answered `fires"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 5Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 , q Commonwealth of Massachusetts e Title 5 Official. inspection Form Subsurface Sewage Disposal System Form-,Not for Voluntary Assessments' 201 Scudder Lane . Property Address Suzi Newman Owner Owner's Name information is , required for every Bamstable *' i MA ,-02630 - 12/10/13 page. City/Town state „Zip Code.- ,..Date of Inspection C. Checklist x L •a Check if the following have been done.You;must indicate.'yes"or"no"as to each of the follo'wing: Yes No : . . N ❑ Pumping information was provided by the owner, occupant,or.Board of Health '❑ ® Were any of.tte system components`pumped out in the previous two weeks? ti y ® ❑ Has the system received normal flows in the previous two week period? El ® 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 t ' ® ❑ available note as N/A) M 1 -T Was the facility or dwelling inspected for signs of sewage back a ?- , r �y 9 P 9 9 P ® ❑ Was the site inspected for signs of break out? - ®' ❑ Were all system components,excluding the SAS,located'on site? i ,- ® ❑• - f 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? k. 'The size and location of the Soil Absorption System(SAS)on the site has- been determined based on:. 4 1z .' ❑, Existing information. For example, a plan at the Board of Health. r Determined in the field (f any of the failure criteria related to.Part Cis at issue I ® ❑ approximation of,distance is unacceptable)P10 CMR 15.302(5)] D. System Information Residential Flow Conditions: : : , • ..Number of bed� . ,,. . . - µ •. • rooms(design): 4 Number of bedrooms(actual): 4T 440 DESIGN flow based on 310 CMR'15.203(for example_'110 gpdx#of bedrooms):' t5ins•11/10 .i - - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17, _" Commonwealth of Massachusetts x Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 201 Scudder Lane Property Address '. Suzi Newman Owner Owner's Name ; information is required for every Barnstable MA 02636 12/10/13 , page. Cityrrown State Zip Code Date of Inspection D. System Informationm Description: Number of current residents: , f 4 Does residence have a garbage grinder?: # 4 ❑, Yes ® 'No Is laundry on a separate sewage system?{if yes separate inspection required]' " ❑ Yes ® No Laundry system inspected?' r Yes ® No Seasonal use? ®`Yes ❑ No Water meter readings,if available(last 2 years usage (gpd)):'. Detail: Sump pump?,. es o Last date of occupancy e ! : t, 09/13 Date Commercial/industrial Flow Conditions: 7. 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? El Yes" ❑FNo 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 _ Tdte 5Official Inspection Form:Subsurface Sewage Disposal System=Page 7 of-17 a r Commonwealth of Massachusetts . Title 5 Official Inspection Form , s Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments 201 Scudder Lane ' Property Address Suzi Newman Owner Owner's Name , r information is ' required for every Barnstable MA 02630 F 12/10/13 page. City(rown State_.' Zip Code Date of Inspection D. System Information (cont.) ; Last date of occupancy/use: g Date _ , Other(describe below): General Information, . - , 'yam � •• , 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;. E x Type of System:,* �. ® k Septic tank,distribution box,soil absorption system w '. 'Single cesspool ❑ Overflow cesspool` Privy,m ' 4'❑ Shared system.(yes ror no)'(f yes,attach previous inspection'records,if any) r r ❑ ylnnoVative/Altemative technology.Attach'a copy of the current operation and . maintenance contract(to be obtained from system owner)and a copy of latest inspection ofthe I/A system by system operator under contract• ` ❑ Tight tank.Attach a copy of the DEP approval. " El Other(describe): Tme5 Official In Inspection Form'Subs urface Sewage Disposal System•Page 8 of - � 9 P Y 9 17 P Commonwealth of;Massachusetts Title 5 Official Inspection Foam s _ Subsurface Sewage Disposal System Form Not for Voluntary Assessments 201 Scudder Lane, . Property Address Suzi Newman Owner Owner's Name information is required for every Barnstable V1. MA `02630 12/10/13- page. Citylrown State ' " Zip Code Date of lnspeotion- D. System Information.(cont.) Approximate age of all components,date installed (if known)and source of information: 20 years y Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade:., i > a 2.3 t 4, feet Material of construction: ❑ cast iron ®40 PVC s ❑ other(explain):, a Distance from private water supply well orsuction line: feet e Comments(on condition of joints,'venting;,evidence of leakage,etc.) • Septic Tank(locate on site plan): ' Depth below grade: . • feet". Material of construction' 1: ® concrete ❑ metal ❑fiberglass ❑polyethylene W ❑ other(explain) 1f tank is metal,list age: years Is age confirmed by,a Certificate of Compliance? (attach a copy of certificate) ❑.Yes ❑ No Dimensions: 1,000 gal Sludge depth: 2,} t5ins•t t/10 Titfe 50fricial Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts IJ Title 5 Official Inspection Form Subsurface Sewage Disposal System,Form-Not for.Voluntary Assessments 201 Scudder Lane Property Address c Suzi Newman' P. Owner Owner's Name J information is required for every Barnstable x MA 02630' 12/10/13 - page. Cityfrown State Zip Code Date of Inspection D. System Information (cont ) Septic Tank (cunt.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness F ' 2.. a 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" W How were dimensions determined? f measured Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): The tank was sound and tight with tees in place and liquid at outlet invert. 41 Grease Trap (locate on site plan): Depth belowgrade: feet r Material of constnlction: ❑ concrete El metal El , El polyethylene R ❑ other(explain): - 'Dimensions: - r 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 y Commonwealth of Massachusetts k . W Title 5 Official Inspection .Form 4 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 201 Scudder Lane Property Address Suzi Newman • r Owner Owner's Name information is required for every Barnstable MA 02630 12/10/13 page. City(rown State Zip Code `" "Date of Inspection D. System Information (cost) Comments(on pumping recommendations,inlet and outlet the 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) (locateon site'plan):' Depth below grade: Material of construction: • ' ❑ concrete El metal ; ❑,fiberglass El polyethylene ❑ other(explain) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present:♦ ❑ Yes ❑ No Alarm level: Alarm in working order: El Nei ❑'No Date of last pumping: Hate t Comments(condition of'alarm and float switches,etc.):" = ' 4 ! k *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11110 Tdle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official, Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 201 Scudder Lane s Property Address Suzi Newman Owner Owner's Name - - - w information is Barnstable 02630''F 12/10/13 ' required for every page. Cityrrown State v_ Zip Code, h.; -Date of Inspection D. System Information (cent )., - Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert even t » 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.): The box was level,and tight with Jno sign of carryover. » yy f' Pump Chamber,(locate on site plan) Pumps in working order, El. Yes El' No Alarms in working order ,•: ` ' El 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-hot located,explain why: t5ins-11/10 ' Title 5 Official Inspection Form:Subsurface Sewage DisposalSystem•Page 12 of 17 41. - r • _. r .,. i Commonwealth of Massachusetts Title 5 Official Inspection Form sr Subsurface Sewage Disposal System,Form-Not for Voluntary Assessments 201 Scudder Lane Property Address Suzi Newman Owner Owner's Name , information is re Barnstable MA 4 0 630 12/10/13 wired for eve 2 Q every Cit /Town State Zip Code page. Y - P Date of Inspection D. System Information (gong) t Type: . k ❑ leaching pits number: ❑ ; leaching chambers. . riumber:`R`a ` ❑ leaching galleries f, number:' , leaching trenches „ number, length: ® leaching fields 4number,dimensions: "1@16'x26 ❑ overflow cesspool* . number+ ' 4 El innovative/alternative system Type%nameYof technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,'damp soil,condition of vegetation,etc.): .. This system has a 16'x26'stone�field with four lines.There was no�sign`of ponding or failure in the stones. Cesspools (cesspool must be pumped as part of inspection) pocate,on site plan): Number and configuration Depth—topµof liquid to inlet invert b. Depth of solids layer w Depth of scum layer Dimensions of cesspool Materials of construction = n Indication of groundwater inflow ❑ Yes ❑ No t5ins-11/10 Title 5Official Inspection Form;Subsurface Sewage Disposal System•Page 13 of 17 I - Comm onwealth of Massach ..., usetts .- Title 5 Official ,Inspecti®n �orrn r Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 201 Scudder Lane Property Address , Suzi Newman r Owner Owner's Name information is required for every Barnstable 1 MA 02630 12/10/13 page. Cityrrown State Zip Code Date of Inspection D. System Information'(cont.) s 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 is , - • , .,, • . Depth of solids 7 Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): j F • ' �L ' ` I � ,� •,� ••' .fir , ,,� ''' , i t5ins•11/10 1 ` n Title 5 Offrcial Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection F&MI ; & Subsurface Sewage Disposal System Form Not for Voluntary Assessments ro 201 Scudder Lane Property Address a.." , Suzi Newman Owner Owner's Name information is required for every Barnstable 'MA 02630 12/10/13 page. a City/Town ' State` 'Zip Code IDate 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 landm6rks 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 n s ❑ drawing attached separately 7n « .� 61 28 24 Y r `t5ins•11/10- •-Tite 5 Official Inspection Form:Subsutface Sewage Disposal System•Page 15 of 17 , Commonwealth of Massachusetts,v �¢ e Title 5 Official Inspection Forma s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments' 201 Scudder Lane Property Address - Suzi Newman Owner Owner's Name , information is required for every Barnstable MA f 02630 12/10/13 page. Cltyfrown State f 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 pate , . ®_• Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: . a ❑.. Checked with local.excavators,installers,(attach documentation) Accessed USGS database;-explain: You must describe how you established the high ground water elevation: augered to 10.0 feet andfound no water. ('adjusted to 8.Tfeet. Bottom of leaching is at 4.2'feet:' - i •a Before filing this Inspection Report,please see Report Completeness Checklist on next page.,. . t_5ins w 11/10 • .. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16.of 17 - Commonwealth of Massachusetts Title 5 Officiaol Inspection z - s Subsurface Sewage Disposal System Form-Not for.Voluntary Assessments ; ' 201 Scudder Lane y Property Address ` Suzi Newman s. Owner Owner's Name } information is required for every Barnstable IM 02630 12/10/13 _ page. City/Town State Zip Code t Date of Inspection - E. Report Completeness Checklist ® Inspection Summary:A,B, C,D,or E checked w " ® Inspection Summary D,(System Failure Criteria Applicable to All Systems)completed ; 4 ® System Information Estimated depth,to high groundwater ® Sketch.of Sewage Disposal System either drawn on page 15 or attached in separate file, ° t5ins,•11110 _ - TNe5Official Inspection Form:Subsurface Sewage Disposal System•Page-17 of 17 1 TROY WILLIAMS � \' SEPTIC INSPECTIONS Certified by MA Department of Environmental Protection MAY (508) 385-1300 19 Hummel Drive *° �'' r��,� 1 4 199 South Dennis, MA 02660 COMMONWEALTH OF MASS ACHU SET TS EXECUTIVE OFFICE OF ENVIRONMENT-L,AFFAIRS O Q PROTECTION DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON, MA 02108 617-292.5500 WILLIAM F.WELD TRUDY CORE Govcmor Sccrctzn ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION Property Address: a0/ Sc,,AJe,1-�.t^. 3G�„SAS/� p rtY Address of Owner: Date of Inspection: /s 8 198 (Ifdi fferent) _ Name of Inspector: Troy Williams - ab_ i30X y 9 - I am a DEP approved system inspector pursuant to Section 15.340 of Title S (310 CMR 15.000) / Company Name: Troy .Williams Septic Inspections /3u✓hSOfe� /t'1�.. Mailing Address: 19 Hummel Driyp . South f)pnnis ,' MA -02660 v263o Telephone Number: ( 50 8T38 5-13A 0 ! CERTIFICATION STATEMENT i 1 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 inspection: The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes s Conditionally Passes Needs Further Evaluation By the Local Approving Authority, Fails �. / C Inspector's Signature: 5tivz, a✓� Date: s/8//1p' w The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(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 w 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. INSPECTION SUMMARY: Check A, 8, C, or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310.CMR I S.303. Any failure criteria not evaluated are indicated below. COMMENTS: .r s t B] SYSTEM CONDITIONALLY PASSES: ^y/4 s.. 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. Indicate yes, no, or not determined (Y, N,or ND). Describe basis of determination in all instances. If"not determined', explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty(20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. ir••.i.•d 04/25193) _ - ..G..q• 1 0! 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued') 201 Scudder Lane,Barnstable, MA `' Property Address: Barbara Moore Owner: May 8 1998 Date of Inspection: ` B) SYSTEM CONDITIONALLY PASSES (continued) // Sewage backup 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). Describe observations: broken pipe(s) are 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 pipe(s). The system will pass inspection if(with approval of the Board of Health): , broken pipe(s) are replaced w • ` obstruction is removed A C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: A1119 Conditions exist which require further evaluation by the Board of Health in order to public health, safety and the environment. determine if the system is failing to protect the r 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 THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water { Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh: 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, It APPROPRIATE) DETERMINES'THAY_ THE SYSTEM IS FUNCTIONING_ IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE - ENVIRONMENT: The system has septic tank and soil abs tributary to a surface water supply orption system (SAS) and the SAS is within 100 feet to a surface water supply,or " The system has a septic tank and soil absorption system and the SAS is within aM1Zone I of-a public water.supply well. The system has a septic tank and soil.absorption system and the SAS is within 50 feet of private water supply well. The system has a septic tank and soil absorption system and the SAS 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 that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 201 Scudder Lane,Barnstable, MA Owner: Barbara Moore Date of Inspection: May 8, 1998 D) SYSTEM FAILS: You must indicate ei;•.er "Yes" or "No' as to each of the following: - 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. Yes No - Backup of sewage into facility or system component due to an 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high.groundwater elevation. Any portion of a cesspool or privy is within I 0 feet of a surface water supply 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 front a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above:' The system serves a facility with a design flow of 10,000 gpd'or greater (Large System) and the system is a sign ificant.threat to public health and safety and the environment because one or more of the following conditions exist: Yes No _ the system is within 400_feet of a surface drinking water supply L 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) " 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 6 CHECKLIST 201 Scudder Lane,Barnstable, MA Property Address: Barbara Moore Owner: May 8 1998 , Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes i No Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components.have been pumped for at least two weeks and the system has been receiving normalflow rates during that Period. LarBa volumes of water have not been Introduced into the as system recent)part of this inspection. Y y or As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. _ 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 the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material-of construction, dimensions, depth of liquid, depth of sludge, depth of scum. _The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal System. N� Existing information. Ex. Plan at B.O.H. ' _ Determined in the field (if any of the'failure criteria related to Part C is at issue, approximation of distance is unacceptable) 115.302(3)(b)) t (-i-d 04/25/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Pr 201 Scudder Lane,Barnstable, MA Property Address: . �. P Y ess: , Owner: e Barbara Moore •Date of Inspection: May 8, 1998 RESIDENTIAL: FLOW CONDITIONS . ; Design flow: 11 d g.p.d./bedroom for S.A.S. Number of bedrooms: y Number of current residents: ? Garbage grinder (yes or no):�S r Laundry connected to system (yes or no): Seasonal use (yes or no): A/6 Water meter readings, if available (last two (2)year usage (gpd): 7' ��J h's 96 y7 �� vv Sump Pump (yes or no): NG y J Last date.of occupancy: Occ 'p u('. k f COMMERCIAUINDUSTRIAL- Type of establishment: - Design flow: galIons/day 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: r. Last date of occupancy: P cy: - - OTHER: (Describe) ` Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: " c T+`�h lJ c r i n r r z System pumped as pan of inspection. (yes or no)LSlU � 1(yes, volume pumped: gallons Re ason for pumping: m ing. , TYPE F SYSTEM Septic tank/distribution box/soil absorption system Single cesspool m Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) { I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information:k U►—, �, ; max" o t� Sewage odors detected when arriving at the site: (yes or no) AJo SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) , Property Address: 201 Scudder Lane,Barnstable, MA Owner: Barbara Moore Date of Inspection: May 8, 1998 BUILDING SEWER: A,1119 (Locate on site plan). Depth below grade: Material of construction: cast iron 40 PVC _ other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.), " SEPTIC TANK: (locate on site plan) Depth below grade: /8 u s r;s-'s +1, 1 Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance (Yes/No) Dimensions: .5 X `j �X � � /DUU qca //0�1 s Sludge depth: 3/' Distance from top of sludge to bottom of outlet tee or baffle: No Tee Scum thickness: Distance from top of scum to top of outlet tee or baffle: NO Tit Distance from bottom of scum to bottom of outlet tee or baffle:�7�t ; How dimensions were determined: Comments: (recommendation for pumping, condition of inlet and outlet tees or 4aHles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) _/l/o S ; c, t 'y><` c J� COL J 4e-C S 4 r- r /V O t ✓ r 7�7—✓ C (�iJ .�� r c t c r. o h 1•� I L� D (/ O�/ r/ - 4 / 6h J �cd &J t J St C-r✓ yc/� e« k d i ` �/ S 4 S - GREASE TRAP 1 (locate 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:' r- Date f ola st um in , P P _g� - Comments: v (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (f-1—d 04/25/97) I SUBSURFACE SEWAGE DISPOSAL SYSTEMINSPEC TION ON FOR M M I PART C SYS TEM INFORM ATION ON (continued) 201 Scudder Lane,Barnstable, MA Property Address:Owner. Barbara Moore Date of Inspection:May 8, 1998 t ' TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) ' (locate on site plan) Depth below grade: , Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) ' Dimensions: Capacity: gallons a Design flow: gallons/day Alarm level: Alarm in working order Yes•. No Date of previous pumping: — w Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) ` Depth of liquid level above outlet invert: l!'/ Comments: (note if level a d distribution is equal, evidence of solids carryover, evidence of leakage into or ou l t of box, etc.) O -fjo I � S h c. Q r c.Q e_r / S 5 h C o o .fi✓ O✓ L j + T PUMP CHAMBER: (locate on site plan) a r 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.) ' 1 # SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .. PART C SYSTEM INFORMATION (continued) Property Address: 201 Scudder Lane,Barnstable, MA Owner: Barbara Moore Date of Inspection:May 8, 1998 SOIL ABSORPTION SYSTEM (SAS): j (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type leaching pits, number:_ leaching chambers, number,_ leaching galleries, number: leaching trenches, number,length: " leaching fields, number, dimensions: . o h - /6 X J? -. overflow cesspool, number: Alternative system: 1 0 Name of Technology: • Comments: . . 4 (note condition of soil, signs of hydraulic failure, level of ponding, condition"of vegetation, etc.)• Sv1I a s ✓ ,� w✓a �cti r� f µ CESSPOOLS: �/� (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: - :• Depth of solids layer: Depth of scum layer: F Dimensions of cesspool: Materials of construction: b _ .Indication of groundwater: inflow(cesspool must be pumped as part of*nspection) _ Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) - PRIVY: (locate on site Ian Materials of.construction: _ Depth'of solids: Dimensionsi 5. Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) . V.q. a of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 201 Scudder Lane,Barnstable, MA - Owner: Barbara Moore Date of Inspection: May 8, 1998 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (locate where public water supply comes into house) Tw k 29, d� —go X 4 /6 XI?6 X j (rwised 04/25/97) P.C. Vof to - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 201 Scudder Lane,Barnstable, MA Owner: Barbara Moore Date of Inspection: May 8, 1998 Depth to Groundwater Feet adjusted high groundwatcr lewd Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps w Check pumping records Check local excavators, installers Use USGS Data Describe. in your own words how you established the High Groundwater Elevation: Must be completed) 6J ti LC_ A M J�, 6 % ice �� � 4s �. � fn q .� „`�-� �o (✓Ci- -rC�C/ � Ll •.. !/1 <'� h r O t� L`� _ cti-'f--c✓ /-GV-���,.� y _ • . *try c -.. d 0 971 Papa 10`ot ]F 1 "