Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
0142 BAY LANE - Health
142 BAY LANE, CENTERVILLE A= s UPC 12534 No.2LOR NA8TIN09,.YN s TOWN OF BARNSTABLE LOCATION ��� �/�y �� SEWAGE 907 VILLAGE �'J��' ASSESSOR'S MAP&PARCEL -"Rtr 9 .0 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY ��/•1T/�'� �S"O® �r'�I.. LEACHING FACILITY:(type).�c2 ',ap�p�Gr (size) NO. OF BEDROOMS OWNER 725'v PERMIT DATE: veal���` COMPLIANCE DATE: `ram P®000�r Separation Distance Between the: ^- a e 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 (CIA FAo*T / /, ya A co a9 It No. D Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 9ppliLation for MispoSaf onstrUttion Permit Application for a Permit to Construct( ) Repair( ) Upgrade( n ) ❑Complete System Individual Components Location Address or Lot No. % � ��')/ Z Ao- Owner's Name,Address,and Tel.No. Assessor's Map/Parcel ���' T p4> Installer's Name,Address,and Tel. Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building : 're" r No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided ��� gpd Plan Date �' o --` Number of sheets J° Revision Date Title Size of Septic Tank - �/�'T��"'� ��oG'' Type of S.A.S. �G'����® ' Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by—Ns Board o ealth. d 2 Date Application Approved by Date Application Disapproved by Date for the following reasons A on Permit No. Date Issued !016. Fee -` No. A computer: Entered in com 1 THE COMMONWEALTH OF MASSACH;USETTS -PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 4plicatioii for bisposAY 6p8t 't11 Construction Permit \ Application for a Permit to Construct( ) Repair( ) Upgrade( � � s ) ❑Complete System Individual Components Location Address or Lot No./1!� �jer� w v 'Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. G 6:;g?ae4!/ 77�..®'�,�, .p.4 vim,jj ��7. c , Type of Building: � t�. -- Dwelling No.of Bedrooms Lot Size J sq.ft. Garbage Grinder( ) ` Other Type of Building 4�r e-j ' No.of Persons Showers( Cafeteria( )' Other Fixtures Design Flow(min.required) l/S/dP gpd Design flow provided gpd Plan Date � .,�t7/S- Number of sheets / Revision Date Title Size of Septic Tank .��f/1'�/� ./0'51P a' Type of S.A.S. tOl'Ge'GZ�//�"✓�°'Gf" Description of Soil Nature of Repairs or Alterations(Answer when applicable) ..I V'W' �e yp! a, Date last inspected: Agreement: % The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued rlf,%,nd Board of ealth. Date Application Approved by / 1�, - Date , Application Disapproved by f (� y Date J for the following reasons Permit No. / Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned( )by �7"�!7'J F'�'O vim. at /1 0001.r �a�'y .�✓+� C dr,, has been constructed in acco dance with the provisions of Title 5 and the for Disposal System Construction Permit NoC / -/ dated Installek leer �`�i�-' Designer 4n44,X� d9r/W,4✓''®.-" &0t P #bedrooms Approved design flow 3 '>4"!' gpd The issuance of this permit shall not be construed as a guarantee that the system wi n f on as designe/ . r Date f ` Inspector 1 Fee- THE No. ----•-------------- ------------ ---------- ----------------- -----=--------- THE COMMONWEALTH OF MASSACHUSETTS �UBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS 33isposal *psteiii Construction Permit Permission is hereby granted to Construct( ) Repair(yj� Upgrade( ) Abandon( ) CO � System located at J �' f/ /✓ c. !-.ter and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Cons tion mu be completed within three years of the date of this permit. r^ Date Approved by Y i Town of Barnstable oEVE'bw, Regulatory Services a Richard V. Scali, Interim Director MAS&"erg! Public Health Division Q, i6396 Thomas McKean,Director , 200 Main Street, Hyannis,INLA.02601 Office: 508-863-4644 Fax: 508-790-6304 Installer&Designer Certification Form '5=�, -- Assessor's M- a \Parcel ilo Z9 Date: Sewage Permit# P Designer: V ._Mj�G Installer: 111 Address: t h `j K � — Address: _414' 1W 1_5 On r was issued a permit to install a (date) (installer) septic system at Z, based on a design drawn by L� (address) ��) dated \ (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tarilk. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out (if required) was inspected and the soils were found.satisfactory. I certify that the system referenced above was constructed ' rice with the terms of the IAA approval letters (if applicable) /�N OF 4.� DAVID (11' 2�av_ INIASON (Installer's Si, ature} t,a tdo.tc5o (D to s to-nature (Affix Desi p Here) PLEASE RETURN TO BARtNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE -OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUTLT CARD ARE RECE1�'ED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:1Se�cicNDe3i;ner certification Form Rev 3-14-13.duc Town.of Barnstable P /Ale. 9 F Department of Regulatory Services mmwarrAB Lm Public Health Division Date � 200 Main Street Hyannis MA 02601 EEU Mld Date Scheduled Time I Fee Pd./Od . 1 t Soil Suitability Assessment for sewage Dispos Z Performed By: Witnessed By: LOCATION& GENERAL INFORMATION Location Address Owner's Name Address Assessor's Map/Parcel: � � 9/9 Engineer's Name"W/� e, el f/ jro, NEW CONSTRUCTION REPAIR h Telephone# -;� Land Use Slopes(%) Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) c / I \ l Parent material(geologic) Depth to Bedrock Depth to Groundwater. Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: In, Depth to soil mottles: In. Depth to weeping from side of obs.hole: in, Groundwater Adjustment ft. Index Well# Reading Date: Index Well level_ _ Adj.factor AdJ.Groundwater Level m PERCOLATION TEST Date � Time„��, Observation Hole# �r Time at 9" Depth of Pere _ Time at 6" Start Pre-soak Time @ L► / Time(9"-6") End Pre-soak . 6l Rate Min./Inch ` Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(YIN) Original: Public Health Division f Observation Hole Data To Be Completed on Back--------- .***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one(1)week prior to beginning. Q:\SEPT[C\PERCFORM.DOC e DEEP.OBSERVATION HOLE LOG Hole# ti Depth from Soil Horizon Soil Texture .Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Stnucture,Stones;Boulders. onsi_ stency %Gravel) 0 I DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. onsistenGravel) DEEP OBSERVATION HOLE LOG Bolo# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Con i to c O DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders, Consistency, a Flood Insurance Rate Map: Above 500 year flood boundary No— Yes Within 500 year boundary Not/ Yes.. ti. Within 100 year flood boundary No,, Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring perviotyg terial exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth cif na rally occurring perv' us material? Ceftifiication p I certify thst on I0 U ;lute I have passed the sril evaluator examination approved by the __ Department of Environ 'e al Pro ction and that the above analysis was performe by me consistent with . the r ning,ex 'se d xp a ce described in 10 CMR 15.017. Signatur Date +� Q:IS EPTICIPERCFORM.DOC r 1, Commonwealth of Massachusetts MlP 1F&- aa9"D0oZ R33 Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 142 Bay Lane _ Property Address Ralph Tolbert Owner Owner's Name information is required for every Centerville ✓ — MA 02632 4/23/15 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: �) / key to move your ! / cursor-do not _Michael DiBuono _ use the return key. Name of Inspector -- DiBuono_S_e_wer and Drain Q Company Name 8 Johns path _ Company Address -- -- - � S Yarmouth _ _ MA _ 02664_ _ City/Town State Zip Code 508-364-9587 _ S113522 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 Basses ® Fails ❑ Needs Further Evaluation by the Local Approving Authority �. 4/23/15 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future u der, the same or different conditions of use. I V t51ns-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 p Y Y aC 142 Bay Lane Property Address Ralph Tolbert Owner Owner's Name information is required for every Centerville MA 02632 4/23/15 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: The system contains a 1,500 gallon tank as well as a concrete Distribution box and 4 infultrators. The system is in hydrualic failure. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if.a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 142 Bay Lane M Property Address Ralph Tolbert Owner Owner's Name information is required for every Centerville MA 02632 4/23/15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will Pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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•3113 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 3 of 17 �h yy &�j �� Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 142 Bay Lane Property Address Ralph Tolbert Owner Owner's Name information is required for every Centerville MA 02632 4/23/15 page. CityrTown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 142 Bay Lane Property Address Ralph Tolbert Owner Owner's Name information is required for every Centerville _ MA 02632 4/23/15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must,be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 142 Bay Lane Property Address Ralph Tolbert Owner Owner's Name information is Centerville MA 02632 4/23/15 required for every i page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ? ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? El Z Have large volumes of water been introduced to the system recently or as part of this inspection? Ej 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? [j Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4-- DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 142 Bay Lane �M Property Address Ralph Tolbert Owner Owner's Name information is required for every Centerville MA 02632 4/23/15 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: The system contains a 1,500 gallon tank as well as a concrete Distribution box and 4 infultrators. The system is in hydrualic failure. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 299.5 gpd g ( Y 9 (gpd)): Detail: 2013: 111,000 gal - 2014: 107,000 gal Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 142 Bay Lane Property Address Ralph Tolbert Owner Owner's Name information is required for every Centerville MA 02632 4/23/15 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: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes; attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 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 142 Bay Lane Property Address Ralph Tolbert Owner Owner's Name information is required for every Centerville MA 02632 4/23/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 22 years Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 18 feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): System is vented throu ht the roof Septic Tank (locate on site plan): Depth below grade: 1 ft feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 gallon If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Gallon Sludge depth: 3" 151ns•3/13 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 142 Bay Lane Property Address Ralph Tolbert Owner Owner's Name information is required for every Centerville MA 02632 4/23/15 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 24" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 42" Distance from bottom of scum to bottom of outlet tee or baffle Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): System is in failure Grease Trap (locate on site plan): Depth below grade: NA feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El 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-3113 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 142 Bay Lane Property Address Ralph Tolbert Owner Owners Name information is required for every Centerville MA 02632 4/23/15 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.): Baffles are in place and levels are normal. 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 El other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 142 Bay Lane Property Address Ralph Tolbert Owner pwner's Name information is required for every Centerville MA Q2632 4/23/15 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 Rotted and decayed Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(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.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 142 Bay Lane Property Address Ralph Tolbert Owner Owner's Name information is Centerville MA 2632 4/23/15 required for every Q page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 4 ❑ 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.): $ystem is in hydrualic 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•3/13 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts R. W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 142 Bay Lane Property Address Ralph Tolbert Owner Owners Name information is required for every Centerville MA 02632 4/23/15 page. City/Town State Zip Code gate of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): System is in hydraulic failure. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 142 Bay Lane Property Address Ralph Tolbert Owner Owner's Name information is required for every Centerville MA 02632 4/23/15 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 t51ns•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 15 of 17 WN OF BARNSTABLE LOCATION "NESEWAGE # Gl�c� VILLAGE S lo-Fee U k.-c-A-- ASSESSOR'S MAP & L '� �-OaeOlq2 INSTALLER'S NAME & PHONE NO. / Z i SEPTIC TANK CAPACITY�Q� r / LEACHING FACILITY:(type 04U (size) INO. OF BEDROOMS �"" PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLI-ANCE ISSUED: VARIANCE GRANTED: Yes No �a AD lQf W G n i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 142 Bay Lane Property Address Ralph Tolbert Owner Owner's Name information is required for every Centerville MA 02632 4/23/15 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: S ® Check Slope ® Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 9.5 + ft 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: r ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Test hole data indicates water at 9.5 ft below surface. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 I. �. Commonwealth of Massachusetts H W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 142 Bay Lane Property Address Ralph Tolbert Owner Owner's Name information is requireO for every Centerville MA Q2632 4/23/15 page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist El Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information — Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 17 of 17 T WN OF BARNSTABLE LO ATION 7j 2 SEWAGE # 2 r VILLAGE � �'6� ` EP Q 1 S ASSESSOR'S MAP & LO� INSTALLER'S NAME & PHONE NO. AA 2&2- (eoq,0 SEPTIC TANK CAPACITY J500 LEACHING FACILITY:(type) A (size) /&f �b l NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER Al r6g(-rtl DATE PERMIT ISSUED: _ /.b DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No e a 77 y tA 4\ I . TOWN OF BARNSTABLE � Li?��"�`"1��N l �'R•�A�l I�y�Q SEWAGE #' q a" Ll 11'z.LAGE Ce.61 r-�A ASSESSOR'S MAP & LOTl�f6"Ga°►'oo� INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /SOU 1 LEACIiING FACILITY: (type) flaw >;M$Or S (size) ��,X 3 i NO.OF BEDROOMS BUILDER OR OWNER bAvid rOW6 PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the. Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Fu-nishe?by - G�r�a _ q,. f3a. 3a la 01 y ray- sa Fmc.--.........L5.... - THE COMMONWEALTH OF MASSACHUSETTS BOAR® F HE TH I/ Y14, 10Z ?f App irFation for Mqpas al Works Tomitrudion Vrrmit Application is hereby made for a Permit to Construct (4or Repair ( ) an Individual Sewage Disposal System t . - ddre or Lot No. . .. Owner Address a .............`..!..1 �----------------•---....•...........................- ...__ !C__ ..._..._......_.`- L Installer Address Type of Building Size Lot....A!�gZ4---------Sq. feet a Dwelling—No. of Bedrooms ..__.___.._____________________________Expansion Attic (�f)J Garbage Grinder p., Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a d Other fixtures .........-•------•-•--•-•-••-•-----•-------•--------__-•-•-------------•-----•--••----------•----•-------••-•---------------------------------------- W Design Flow.......5 t_s.o. ----------- per person per day. Total daily flow.......... ...................gallons. I4 Septic Tank—Liquid capacity.A allons Length.IC?-_!__.. Width.15- ._.. Diameter- __----- Depth..S._... Disposal Trench—No. ................... Width....(P.......... Total Length...... C:_...... Total leaching area_-4.IR4Q.....sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box `7� Dosi nk (1�o , I ii '-' Percolation Test Results Performed b � - ...4�(. 4 ._____._ Date_._. _ _ _ W Y.- . Test Pit No. I...L2------minutes per inch ,Depth of Test Pit...1.0......... Depth to ground water_-40YE"C0-11-Q Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ - --------------------- ---------•----••-----..--•---------------•---•---------- O Description of Soil----0." -. ®�w1 A........�'b` 91�' x V •••-------------------------•-------........•---••--•--•-•--••-•-------------------.........-------------••-----•----•--•---•---------------......------••-•-------•......•••- W UNature of Repairs or Alterations—Answer when applicable---- SIGN6fJG--F.-.-•--•____________________•---•--_ �h MLLATIC� jupekftE-------- ,iv I�INf Agreement: AC^Opr,�.- . --D IN STRIC The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with �'1T�'iF r? the provisions of iT::.. of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued b the rd o healt . j,�' Op - D e Application Approved BY Q ... ............................. r ate Application Disapproved for the following reasons---------------------------------------------------------------------------------••---------•--•----------------- ---------•---------•-•---------------••-•-•-------------------....-•-••--•----------...•-•-••------....-------------------------- ------------------------------------------------------...----- Datc PermitNo.------- ......r.......................... Issued-....................................................... Date i fkA A. G Fzs.......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Application is hereby made for a Permit to Construct (1-1"or Repair ( ) an Individual Sewage Disposal Systmz, t: ..............C� 2=_ � �/j or I.�ot�N�of Owner Addres Installer Address Type of Building Size Lot......li.-_'4:ff�........Sq. feet Dwelling—No. of Bedrooms........., -----------------------------Expansion Attic Garbage Grinder Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ------------------------------•- . W Design Flow....... ` ...........gallons per person per day. Total daily flow--------- 0....................gallons. 04 Septic Tank—Liquid capacity i`?Qgallons LengthlO.-.C' .... Width :.- --. ..... Diameter':""_-._--.-_ Depth..__....-R Disposal Trench—No. _..t................ Width_..!.�2........... Total Length----36:2....... Total leaching area.a.g�------sq. ft. Seepage Pit No-----------.......... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box 6� Dosiw,Y;nk 0 Percolation Test Results Performed by..... _Az� ? MIIC_�...... !Y C._.� L......._. Date... ............ ,aa Test Pit No. L-4,7Z-------minutes per inch Depth of Test Pit...ID.......... Depth to ground water-1 o_'T.�(__&SZ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..-_____----_-_.-.._---. ------------------•-• ..............................................................----._._...... .---------•-----------------------•-- D Description of Soil.... .. ...........' Lc�{.. ti!l• -.aC �_t l yv�.kr:l� x W -----------•----------------------•--••--•-•--••-•••---•---- ---------------....-------------•----------•-------------------•-------•--•- ,. ..... as IP'�R •- VIS-----...---••-•- V Nature of Repairs or Alterations—Answer when applicable..^!:�^.�........................ ............ ,r ------------------------------------------------ Cn ,I WA.S rl .� Agreement: _. vAPF To p��-, The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TTT t.ram. of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health.,,,, r `Z �( -Signed.-.. f�= ...................... ; 7 �` D. to Application Approved BY =- .�z`........................._ Cam•(; � -•--� s=>7 ---... Date ' Application Disapproved for the following reasons:.............................................................................................................. .................................. ...-•---��---�^----�--•-------•--•----•••.....-•-----------------------------••-----•- -•----•••-•---••--•------•----•-----•---•-••-•••--•--•-•----•. Date PermitNo..•..... ':..............•--••�-•-•.._.._..-•...... Issued................................. ------------- Date THE COMMONWEALTH OF MASSACHUSETTS OARD OF HEALTH �� �b� T rtif iratr of Toutphatta THIS IS TOe RT F , That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by � �� ..............................................................•-........_....------........... Installer has been installed in accordance with the provisions of TiTIE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No _0............................ dated_....�.. -.- � .............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRU AS GU ANTEE THAT YHE SYSTEM WILL FUNCT N T.SF T Y. DATE.......... ..C?` Inspector.................. THE COMMONWEALTH OF MASSACHUSETTS �- BOARD OF HEALTH DESIGNING ENGINEER MUST SUPERVISt NSTALLATION AND CERTIFY It-,i v,1RITIN'r 1.�...OF.,.......... ..I�/C�. ..?YSTEM WAS IRSTAI_Lrrt � � vJ 0...................7..... FEE............:............ Dblpv nrkii Talanitrnrtion rrnti# ,p Permission is hereby granted L I___]................................................................................. to Construct �) or Repair an Ind-ivid al Sew e DisTsal System at.No.............................1 -••-•- ••-•--••....................................... 0n-••-••--------•-r-------•--- --•••.._....---••••- Street as shown on the application for Disposal Works Construction Permit I�o:_-..___ _��'..._ Dated..._.1...>..= � ......._. ..........................- - C i. :=:...:.... Board of Health DATE................................................................................ FORM 1255 HOSES & WARREN. INC., PUBLISHERS APPLICATION FOR PERCOLATION TEST AND OBSERVATION PITS LOCATION NO. - 30 VILLAGE I r U i DATE APPLICANT lam✓ 1 �l FEE ADDRESS Non-refundable) TELEPHONE NO��J�L ENGINEER �- TELEPHONE NO. 001 07 DATE SCHEDULED — ,,rLUA (Applicant' s signature) . . . . . . . . . . O . . . . . . O O O O . . . . . . . • O • . O . . • . . . . . O . . . • . . . O . . . . O • . . . . . . . • . O . . . . . . . . . . . . . . . SOIL LOG SUB-DIVISION NAME DATE TIME EXPANSION AREA: YES l/NO /��;�/�_ ������,�,� ENGINEER TOWN WATER ✓PRIVATE WELL BOARD OF HEALTH Z2 EXCAVATOR SKETCH: (Street name,etc. ,dimensions of lot, exact location of test holes and percolation tests, locate wetlands in proximity to test holes) NOTES: ` . 1�- or- z 7-7 V M Z . PERCOLATION RATE: TEST HOLE NO: ELEVATION: TEST HOLE NO: ELEVATION: 2 � ~ 3 .3 4 4 5 5 6 �© 6 7 7 8 8 9 9 10 10 G 70FZL 11 11 • 12 12 13 13 14 .• 14 15 15 16 16 SUITABLE F0R`=SUB*SURFACE--SEWAGE: :LEACHING=FIELD k--LEACHING PITS LEACHING TRENCHES/ UNSUITABLE FOR SUB-SURFACE SEWAGE. REASONS: NOTE : ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED ON PERC TEST APPLICATION ORIGINAL: COMPLETED IN ENTIRETY BY P. E. AND RETURNED TO BOARD OF HEALTH COPY: RETAINED BY APPLICANT Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection �fCEjV f� One Winter Street, Boston MA o2lo8 (617)292-5500 APR `. >•01"' 0 2 0 2000 " �Tr� �a,�� . � . TRUDY COXE �. � Se Mtary ARGEO PAUL CELLUCCI _'.D y[D B.SfRUH,S Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 142 Bay Lome, Centerville, MA Name of Owner: David Rowley Address of Owner: Sane Date of Inspection: April 14, 2000 Name of Inspector: (Please Print) lames M.Ford I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: lames M. Ford Mailing Address: P.O.Box 49, Osterville, MA 02655-0049 Map. 186 Telephone Number: (508)862-9400 Parcel. 029-002 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 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 Conditionally Passes eeds Further Evaluation B th Local Approving Authority 'Is Inspector's Signature: Date: April 1 Z 2000 The System Inspector shall submit y of this inspection report to the Approving Authority(Board of Health ord)EP)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 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. NOTES AND COMMENTS revised 9/24/98 Page 1ofII Prinwd on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 142 Bay Lame, Centerville, MA Owner: Datvid Rowley Date of Inspection: April 14, 2000 INSPECTION SUMMARY: Check A, B, C, or D.- A. SYSTEM PASSES: ✓ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 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. 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 complying septic tank as approved by the Board of Health. _ 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) 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 obstruction is removed revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 142 Bay Lurie, Centerville, MA Owner: David Rowley Date of Inspection: Apfi114, 2000 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 the public health, safety and 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 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 WELL 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 AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and.soil absorption system(SAS)and the SAS is within 100 feet to a surface water supply or �? :tributary to a surface.water supply. , The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet,of a 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 revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 142 Bay Late, Centerville, MA Owner: David Rowley Date of Inspection: April 14, 2000 D. SYSTEM FAILS: You must indicate either"Yes" or"No" as to each of the following: I have determined that one or more of the following failure conditions exist as described 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 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. 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 significant 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 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 upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 142 Bay Lane, Centerville,MA Owner: David Rowley Date of Inspection: April 14, 2000 Check if the following have been done: You must indicate either"Yes"or"No".as to each of the following: .. Yes 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 normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ✓ _ 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 conditions 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: ✓ _ Existing information. For example,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] [15.302(3)(b)l- ✓ _ The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal Systems. revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 142 Bay Lurie, Centerville, MA Owner: David Rowley Date of Inspection: April 14, 2000 FLOW CONDITIONS RESIDENTIAL: Design flow: 110 g.p.d./bedroom. Number of bedrooms(design): 4 Number of bedrooms(actual): 4 Total DESIGN flow n/a Number of current residents: 2 Garbage grinder(yes or no): Yes Laundry(separate system)(yes or no): No; If yes,separate inspection required Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last two year's usage(gpd): 1999-166,000 gals.:1998-160,000 gals. Sump Pump(yes or no): No Last date of occupancy: Crrently occupied COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: gad(Based on 15.203) Basis of design flow 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: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Never pumped-per owner. System pumped as part of inspection(yes or no): No If yes,volume pumped: gallons Reason for pumping: TYPE OF SYSTEM ✓ Septic UuWdistribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records, if any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components,date installed(if known)and source of information: Mar. 26193-per as built card. Sewage odors detected when arriving at the site: (yes or no) No revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL',SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 142 Bay Ilene, Centerville, MA Owner: David Rowley Date of Inspection: April 14, 2000 BUILDING SEWER: _ (Locate on site plan) s 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: 6" 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: 1500 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: I" Distance from top of scum to top of outlet tee or baffle: 9" Distance from bottom of scum to bottom of outlet tee or baffle: 14" How dimensions were determined: Measuring stick Comments: (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.) The inlet tee and outlet baffle were present. The liquid level was even with the outlet invert. Tire scum and solids were mirdmal. GREASE TRAP: None (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: Date of last pumping: Comments: (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.) revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 142 Bay Lane, Centerville,MA Owner: David Rowley Date of Inspection: April 14, 2000 TIGHT OR HOLDING TANK: None (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 Design flow: gallons/day Alarm present: Alarm level: Alarm in working order: Yes_ No_ Date of previous pumping: 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: -- } Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) The box was located, bra not dug up. The box is right beside the tank. PUMP CHAMBER: None (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.) revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC TION FORM PART C SYSTEM INFORMATION (continued) Property Address: 142 Bay Lurie, Centerville, MA Owner: David Rowley Date of Inspection: April 14, 2000 SOIL ABSORPTION SYSTEM (SAS): ✓ (locate on site plan, if possible; excavation not required, location may be approximated by non-intrusive methods) If not located,explain: Type: leaching pits, number: leaching chambers,number: 4-flow diffusors with stone(see design plans) leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.) The flow diffusors were 16"down under a gravel driveway. The bottom to grade was wrox. 3'. CESSPOOLS: None (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(cesspool must be pumped as part of inspection). Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) PRIVY: None (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.) revised 9/2/98 Tage9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 142 Bay Lane, Centerville, MA Owner: David Rowley Date of Inspection: April 14, 2000 Map: 186 Parcel: 029-002 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) �onT \� 4 y1 3 - , a aa- 3A.(o 6 —� A3. f33- a� A4' sa aa- ;L0 O -rts r revised 9/2/98 Pap 10ofll SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 142 Bay Law, Centerville,MA Owner: David Rowley Date of Inspection: April 14, 2000 NRCS Report name Soil Type Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater 9' Feet Please indicate all the methods used to determine Haigh Groundwater Elevation: Obtained from Design Plans on record ✓ Observed Site(Abutting property,observation hole,basement sump etc.) _ Determined from local conditions Checked with local Board of Health; Checked FEMA Maps Checked pumping records Check local excavators,installers ✓ Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Hand augered down to groundwater, which was 9'below grade. Using the Cape Cod Commission Technical Bulletin, the high groundwater adjustment for this site(MIW 29, Zone B, 3100)was 2.9, making the adjusted high groundwater level 6.1'. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. revised 9/2/98 Page 11of11 c �, CERTIFICATE OF ANALYSIS Page. Barnstable County Health Laboratory Resort Preaared For: Report Dated: 11/6/2003 Order Number: G0323279 Fred Thimme 377 Wheeler Road Marstons Mills, MA 02648 Laboratory m#: 0323279-01 Description: Water-Drinking Water Sample#: 23279 Sampline Location: 377 Wheeler Road, Marstons Mills MA Collected 10/21/2003 Collected by: S.Thimme 081/002 Received 10/21/2003 Roxtine ITEM RESULT UNITS MCL Method# Tested LAB:IC Lab Nitrates <0.1 mg/L 10 SM 4500 10/22/2003 LAB:Metals Copper 0.3 mg/L 1.3 SM 3111B 10/24/2003 Iron 0.1 mg/L 0:3 SM 311113 10/24/2003 Sodium 13 mg/L 20 SM 3111B 10/24/2003 LAB: Microbiology Total Coliform Absent P/A Absent 309 10/23/2003 LAB: Physical Chemistry Conductance 102 umohs/cm EPA 120.1 10/21/2003 pH 5,9 pH-units EPA 150.1 10/21/2003 Note: Water sample meets the recommended limits for drinking water of all above tested parameters. Approved By: (Lab Director) Z3 ' tr;x? r' „[,7, 3i1•' 1 _,,:a?1" I 1 1 f ..• -- �i? ;'.: '1`7i. ;!its; \::;7!3 t Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 w BAXTER & NYE., 1K. ,t F Professional Land Surveyors and Civil Engineers 812 Main Street.•Osterville, Massachusetts 02655 Tel. (508) 428-9131 FAX(508) 428-3750 WILLIAM C.NYE,P.L.S.-President PETER SULLIVAN,P.E.-Vice President-Engineering RICHARD A. BAXTER, P.L.S.-Vice President March 29 , 1993 Board of Health Town of Barnstable P .Q. Box 534 Hyannis , Ma 02601 Re: Lot 2 Bay Lane Archibald Realty Trust - Assessor :Map 186 Parcel 29-2 Dear Board : ' In- accordance with the terms of the Disposal Works Construction Permit for Lot 2 I have provided engineering inspection for the installation of the septic system. Based on this it is my professional opinion that the system has been installed as per the approved plan . If you have any quest i ns please feel free to call . Very truly yours , OF Sullivan, P . E . Baxter & Nye, Inc . _PS:slgw «:.w fii fiPL §� SUISIVAN No. 237Z3 MEMBERS OF CAPE COD SOCIETY OF PROFESSIONAL ENGINEERS AND LAND SURVEYORS I AMERICAN CONGRESS ON SURVEYING AND MAPPING MASSACHUSETTS ASSOCIATION OF LAND SURVEYORS AND CIVIL ENGINEERS ASSESSORS MAP: TEST HOLE LOGS C The instillation shall comply with "l'itle V aid Town of rl Board ol_ PARCEL: .,�Z 49 ) � C t y FLOOD ZONE: ,L/ ✓ I�j}=,��,/C SO I L EVALUATOR : * 1 0. I lealth Itegulations. WITNESS: l 2) The installer shall verify the location of utilities, sewer inverts and septic REFERENCE: p� DATE: Q l components prior to installation and setting base elevations. IPERCOLAT I 0 RATE:.0 "Z,' ) t j 3) All gravity septic piping to be 4 inch Scli 40 PVC at 1/8" per foot. The Grst y. 1Z�O. � v, 12 < two feet out of the d-box to the leaching shall be level � 4) This plan is not to be utilized for property line determination nor any other TH 2 TH- I � , � purpose other than the proposed system installation. _S -_ ._�_°_ � !/ 4 AC 0 � i+� fo v� t 5) All septic components must meet Title V specifications. o 6) Parking steal I not be constructed over H 10 septic components. �p 6 � U�� 7) The property is bounded by property corners and property lines. 8) The property owner shall review design considerations to approve of total O'CAT I ON MAP . h' W' � design flow and number of bedrooms to be considered for design. Receipt L of payment for the plan and installation based on the plan shall be deemed V approval of the design flow by the owner. v 9) The existing leaching or cesspools shall be pumped and filled with material per Title V abandonment procedures. Those within the proposed SAS shall nn be removed along with contaminated soil and replaced with clean sand per Title V specs. 10 System components to be 10 feet from water line. Sewer !fines crossing the ) Y p g water line shall be sleeved with 4 inch SCI 140 PVC with ends grouted if \ j applicable. The proposed SAS is being installed below the water service line. The line is to be sleeved as aforementioned and maintained in place. SEPT I C SYSTEM DES I G N 11) If a garbage grinder exists it is to be removed and is the responsibility of(he owner to ensure such. FLOW ESTIMATE 12)The installer is to take caution in excavation around the gas line if such 1 exists. ' \ N BEDROOMS AT GAL/DAY/BEDROOM GAL/DAY 13)Tne installer shall verify the location, quantity and elevation of the sewer lines exiting the dwelling prior to the installation. i 14)This plan is representative only that a system can fit on a property meeting SEPTIC TANK Title V requirements. . I 1 HLGAL/DAY x 2 DAYS GAL USE 00 GALLON SEPTIC TANK6AI,'I �301 L�RPT I ON SYSTEM DAVID y SIDE AREA: B. ` c '., MASON m �. BO TTOM AREA: yr BOTT q TA \\0 f � �-�— 1� �� -�r 1 C SYSTEM SECT I ON Ind of � t�c _� Iw -rrlu 11 D, ��- Li NL b IDh _ )'11-T -f1 � ►� _ Imo_ ._ IU, - 17� G AL l�1 �t�C._. EUN ►gyp, , �" S�E�PT 1 TA Al/ SITE AND SEWAGE PLAN LOCATION : l � -Foy 1- ll4& C�yl PREPARED FOR Cr SCALE: 0 \ � Zo 4 DAV I D B . MASON R`> DATE. W DBC ENVIRONMENIfAL DESIGNS \ \ EAST SANDWICH . MA W \ �� DATE HEALTH AGENT ( 508 ) 833-2 1 77 Z � 77 F 30 --------------- Ike < C—N:j 14 14 144,7 7�f -4-S�O -7 7Z> qtq ii� 4;:: Al C PIT 7-,;7 A::�'1? +1 -Cl -7' Z IT 4W Olz%zGc 10-9 tee [��4 ............ MUT Fy );i�nAVCr INSTALLED IN To Sy�'_I"EA4 WA AND CERM IL /A 4_6 (LOTS.) F�IJ:�), L 7k A wHARD PETER A SULLIVilil Co. 29733 Zoo,\-rt4- a. 770, T7 L