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HomeMy WebLinkAbout0098 BRIDGET'S PATH - Health 98 Bridgets Path t Centerville P u A = 170 237 t No. 42101/3 ORA f ESSELTE 10% O © 0 0 I ` Commonwealth Of Massachusetts ` Executive Office Of Environmental Affairs Department Of Environmental Protection 4' TITLE 5 Official Inspection Form -Not For Voluntary Assessments Subsurface Sewage Disposal System Form Part A Certification Property Address: 98 Bridget's Path Centerville Ma.02632 Owners Name:Edward Gallagher Owners Address: Date of Inspection: 11/5/2008 Sly SZq� Name of Inspector(please print)Sean M.Jones#SI4522 Company Name: S.M.Jones Title V Septic Inspection Mailing Address: 74 Beldan Ln. Centerville Ma.02632 Telephone Number: 774-2484850 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CAM 15.000).The system: X Passes Conditionally Passes Needs further evaluation by the Local Approving Authority Fails Inspectors Signature Date: a /3ai: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments: ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONCINUED) Property Address: 98 Bridget's Path Centerville Ma.02632 Owners Name:Edward Gallagher Owners Address: Date of Inspection: I1/5/2008 Inspection Summary:Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B.System Conditionally Passes:N/A One or more system components as described in the"Conditional Pass"section need to be replaced or Repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the_for the following statements.If"not determined"please Explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally Unsound,exhibits substantial infiltration or exfiltration or the 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 structurally sound,not leaking and if a Certificate of Compliance Indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water,level in the distribution box due to broken or Obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with Approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(S).The system will Pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 98 Bridget's Path Centerville Ma.02632 Owners Name:Edward Gallagher Owners Address: Date of Inspection: 11/5/2008 C.Further Evaluation is required by the Board of Health:N/A Conditions exist which require fitrther 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 310CMR 15.303(1)(b)that the System functioning in a manner that protects the public health,safety and the environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a Surface water supplyor 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 less than 100 feet but 50 feet or more from a Private water supply well".Method used to determine distance ""This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform Bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other Failure criteria are triggered.A copy of the analysis must be attached to this form. i 3.Other: OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(cownquED) Property Address: 98 Bridget's Path Centerville Ma.02632 Owners Name:Edward Gallagher Owners Address: Date of Inspection: 11/5/2008 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than %2 day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of cesspool or privy-is within Zone 1 of a public well. X Any portion of cesspool or privy is within 50 feet of a private water supply well. X Any portion of cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 pp,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] X (Yes/No)The system fails.I have determined that one or more of the above 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:N/A To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: 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 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 CM15.304.The system owner should contact the appropriate regional office of the Department. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 98 Bridget's Path Centerville Ma.02632 Owners Name:Edward Gallagher Owners Address: Date of Inspection: 11/5/2008 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health X Were any of system components pumped out in the previous two weeks? X Has the system received normal flows in the previous two week period? X _Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X Were all system components,excluding SAS,located on site? _X_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tee,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? X_ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been.determined based on: Yes No X_ _ Existing information.For example,a plan at the Board of Health. _X_ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance Is unacceptable)[310 CMR 15.302(3)(b)] OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 98 Bridget's Path Centerville Ma.02632 Owners Name:Edward Gallagher Owners Address: Date of Inspection: 11/5/2008 .FLOW CONDITIONS RESIDENTIAL 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 gpd Number of current residents:-0— Does residence have a garbage grinder(yes or no): no Is laundry on a separate sewage system(yes or no)_no [if yes separate report required] Laundry system inspected(yes.or no):_n/a Seasonal use:(yes or no) no_ Water meter readings,if available(last 2 years usage(gpd): 2006=370 gpd--2007=288 gpd Sump pump(yes or no): no Last date of occupancy/use: 9/2008 COMMERCIAL/INDUSTRIAL:N/A Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping records Source of information: Was system pumped as part of the inspection(yes or no): no If yes,volume pumped: gallons--How was this quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _X Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be Obtained from the system owner) Tight tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewerage odors detected when arriving at the site(yes or no): No OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 98 Bridget's Path Centerville Ma.02632 Owners Name:Edward Gallagher Owners Address: Date of Inspection; 11/5/2008 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: cast iron 40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): Joints were in good condition,no sian of leakage. SEPTIC TANK:_X_(locate on site plan) Depth below grade: 3`_ Material of construction: concrete metal - fiberglass_polyethylene other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 8`6"X5`6"X4`10"= 1000 Gallons Sludge depth: 12" Distance from top of sludge to bottom of outlet tee or baffle: 2.5` Scum thickness: 6" Distance from top of scum to top of outlet tee or baffle:_3" Distance from bottom of scum to bottom of outlet tee or baffle: 6" How were dimensions determined:Opened covers and took measurements Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels As related to outlet invert,evidence of leakage,etc.): Tank needs to be cleaned soon and again every 2 years to maintain the systems useful lifeWan.Outlet tee intact and in good condition.Water level at bottom of outlet invert.Inlet cover under deck,outlet cover on riser. GREASE TRAP: N/A (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(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels As related to outlet invert,evidence of leakage,etc.): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 98 Bridget's Path Centerville Ma,02632 Owners Name:Edward Gallagher Owners Address: Date of Inspection: 11/5/2008 TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present(yes or no): r Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0" Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of Leakage into or out of box,etc.): D-box functioning as intended,no solids carryover and water level was at bottom of outlet invert. PUMP CHAMBER: N/A (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.): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 98 Bridget's Path Centerville Ma.02632 Owners Name:Edward Gallagher Owners Address: Date of Inspection: 11/5/2008 SOIL ABSORPTION SYSTEM(SAS):_X_(locate on site plan,excavation not required) If SAS not located explain why: Type Leaching pits.Number: X Leaching chambers,number: 4 galleys Leaching galleries,number: Leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternitave system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): S.A.S.was located but not excavated. Soil and stone was probed and found to be dry with no sign of past hydraulic overloading. CESSPOOLS: N/A (cesspools must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: N/A (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.): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 98 Bridget's Path Centerville Ma.02632 Owners Name:Edward Gallagher Owners Address: Date of Inspection: 11/5/2008 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 30+ feet Please indicate(check)methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater elevation was determined by accessing Town of Barnstable Groundwater contour map. ~ OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 98 Bridget's Path Centerville Ma.02632 Owners Name:Edward Gallagher Owners Address: Date of Inspection: 11/5/2008 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent referencelandmarks or Benchmarks.Locate all wells within 100 feet.Locate where water supply enters the building front of house b deck 'a TANK 3 i=16' O &1=W 1 2 D-BOX A-2=14V B-2=21V S.A.S. A-3=29 B-3=12° � C) t' r. COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE.OF ENVIRONMENTAL AFFAIRS . DEPARTMENT OFENVIRONMENTAL PROTECTION; • 4AP -� ' PARCEL , �O TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION RECEIVED Property Address: 98 Bridgets Path Centerville, MA APR 2 7 2004 Owner's Name: Joanne Howard Owner's Address: TOWN OF BARNSTABLE HEALTH DEPT. Date of Inspection: Name of Inspector.(please print) Wi 1 1 i am _ .Robinson Sr. Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1089 Centerville, MA Telephone Number: (5081 775-8776 CERTIFICATION STATEMENT 1 eert4that 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 15340 of.Title 5(310 CMR 15.000). The system: .. (✓. Passes ' Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: i t ,�'�- Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heankor. 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 seat to the system owner and copies Sent to the.buyer,if applicable,and the appro.ving authority. Notes and Comments ' ****This report only describes conditions at the time of inspection and under the conditions of use at that time-This inspection does not address how the system will perform in the future under the same or different conditions of.use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of I I T OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 98 Bridgets Path Centerville, MA Owner. Joanne Howard Date of Inspection.:. Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found_ any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated.below. Comments: B. Syitem Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer,yes,no or not determined(Y,N,ND).in the for the following statements.If'!not determined"please explain! e septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unso d,exhibits substantial infiltration or enfiltration or tank failure is imminent.System will pass inspection if the exist4 tank is replaced with a complying septic tank as approved by the Board of Health. •A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: 1 Observation of sewage backup or break out or high static water level in the distribution box due to-broken or obstructed pipes)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed .The system will p Inspection if(with approval of the Board of Health): p (s) broken pipe(s).are replaced. .. , obstruction is inao_vod NO ex lain: Page 3 of I 1 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 98 Bridgets Path Centerville Owner, Joanne Howard Date of Inspection: . /6- G C. I 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 CMIt.15,303(1)(b)that the . system is not functioning in a manner which will protect public health,safety,and the environment: 1 _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.. ` 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: 1 _ 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. P PP Y 6t — The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. f { The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more front a private water supply well" Method used to determine distance i "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and 1 the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than S ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 1 3. Other: i 3 Page 4 of 11 OFFICIAL INSPECTION FORM—.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART A CERTIFICATION(continued) Property Address: 98 Bridgets Path Centerville, MA Owner: Joanne Howard Date of Inspection:. 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 9Liquid depth in cesspool is less than'6"below invert or.available volume isless'than'/,day(low Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number Hof 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 orr'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. �my portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private w•attr supply well with no acceptable water quality analysis.(This system passes if the well water analysis, performed at a DEP certified laboratory.,for coliform bacteria and volatile organic compounds indicates that the well is free.from pollution from(fiat facility and the presence of ammonia nitrogen and nitrate hi(rogen 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.] (P es/No)The system fails.I have determined that one or more of-the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to'correct the failure. E: arge Systems:. T be considered a large system the system must sere a faci!ity with a design now of 10,000 gpd to 15,000 !pd. You must indicate either"yes"or"no"to each of the following: e following criteria apply to large systems in addition to the criteria above) yes, no the system is within 400 feet of a surface drinking water supply the systetn 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 l Zone 11 of a public water supply well if you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"idt Section D above the large system has failed.The owner yr operator of arty large system considered a signific aI�nt threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. h system owner should contact the appropriate.regional office of the Department. 4 Page S of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.B CHECKLIST Property Address: 98 Bridgets Path Centerville, MA Owner Jnannp Howard Date of Inspection: /—c) 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 7. Has the system received normal flows in the previous two week period? _ IV/Have large volumes of water been introduced to the system recently or as part of this inspection?. ✓ Were as built plans of the system obtained and examined?(if they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS,located on site? -L _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _ ✓ Was the facility owner(and occupants if different from owner)provided with information on the.proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no l ✓Existing information.For example,a plan at the Board of Health. y — Determined in the field(if any of the failure criteria related'to Part C is at issue approximation of distance. is unacceptable)[310 CMR 15.302(3)(b)J 5 Page 6 of 11 s OFFICIAL INSPECTION FORM-.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C' SYSTEM INFORMATION Property Address: 98 Bridcrets Path Centerville, MA Owner: Joanne Howard Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):,-5 Number of bedrooms(actual): DESIGN flo w based on 310 CMR 5.203 for example: 110 d x#of bedrooms): `.5r1 � ( P gP ) � Number of current residents:Jam! Does residence have a garbage/grinder(Yes or no):4 A, _ Is laundry on a separate sewage system(yes or no):N [if yes separate inspection required) Laundry system inspected(yes or no):jv Seasonal use:(yes or no): �� Water meter readings,if available(last 2 years usage(gpd)):` 20 0 3 = 322 "0 0 0 r`?o L , Sum um es or no — , 0 0 0 PP pump ).1L 0 Last date of occupancy: �- -v COMM CIAIANDUSTRIAL Type of es blishment: Design 80 (based on 310 CMR 15.203): Qpd Basis f d� i ow eats/ erson ! ft e az s o s flow s s s tc. : - tPt ( P q ) Grease U4 present(yes or no):_ Industriallwaste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water rt��4ter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: 4 ;,ts C_ «✓' Was system pumped as part of the inspection(yes or no):G_0 If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: f - TYP OF SYSTEM _Septic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool _Privy . _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: q� � G '33 Were sewage odors detected when arriving at the site(yes or no): J 6 i ]',age 7 of 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION(continued) Property Address: 98 Bridgets Path Centerville, MA Owner: Joanne Howard Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade:_ Materials of construcuon:_cast iron 40 PVC other(explain): Distance from private water supply well,or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: (locale on site plan) Depth below grade:�_ � Material of construction: lit:oncrete_metal fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confumed•by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: l (E, -t g 'tom Sludge depth: Distance from top of sludge to bottom of outlet ice or baffle: — Scum thickness:�� t Distance from top of scum to top of outlet tee or baffle:,_ Distance from bottom of scum to bottom oC outlet tee or battle: How were dimensions determined: p Al%— C,,� !, A --s' Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): , v C 4 -�fir, GREASE TRAP: (Io pate on site plan) Depth below grade:_ Material of construction/ concrete._metal fiberglass_polyethylene other (explain): ' Dimensions: / Scum thickness: / Distance from top o--scum.to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on puhtping feconunendations,inlet and outlet tee or baffle conditio:,structural integri(y,liquid levels as related to oull'et invert,evidence of leakage,etc.): f 7 Page 8 of 11 OFFICIAL INSPECTION FORM;-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART:C SYSTEM INFORMATION(continued) Property Address:98 Brid ets Path Centerville, MA Owner: Joanne Howard Date of Inspection: TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site.plan) Depth below grade: Material of construct : concrete metal fiberglass.polyethylene other(explain)... Dimensions: Capacity. / allons Design Flow: allons/day Alarm presen (yes or no): Alarm level- Alarm in working order(yes or no): Date of la pumping: Comme s(condition of alarm and float switches,.etc.): DISTRIBUTION BOX: present must be opened)(locate on site plan) Depth of liquid level above outlet invert:0 _ Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: (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.): i 8 Page 9 of I l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 98 Bridctets Path Centerville, MA owner: Jnanna 14nwarr7 Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): o ate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ Aaching chambers,number:, leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow,cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): .0t*0 Q '/k fl"� CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet inve: Depth of solids layer: Depth of scum layer: j Dimensions of cesspool: Materials of construction: 1 Indication of groundwater inflow(yes or no): Comments(note condition f/f soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of constru'ction: Dimensions: Depth of solids:/ Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): i y 9 Page 10 of 1 I 1 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C, SYSTEM INFORMATION(continued) Property Address: 98 Bridaets Path Centerville, MA Owner: eL3rd Date of Inspection: 14 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply a ters the building. ' W,;z 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 98 Bridgets Path Centerville, MA Owner. Joanne Howard Date.of Inspection: r. r C. SITE EXAM Slope Surface water Check cellar Shallow wells 1t Estimated depth to ground water /7/ feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high groundwater elevation: 11 J TOWN OF BARNSTABLE LOCH z7iON Br. � j PA SEWAGE # !;y LL•AGE CLATt/yAk. ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY MO LEACHING FACILITY: (type) L7A161S (size) Frka0- NO. OF BEDROOMS BUILDER OR OWNER G�aI IA5�cr PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by _�n EA y-/t'yr► FD/ e , ' O 133 d-7a 39 C • 10- , COMMONWEALTH OF MASSACHUSETTS �JJ�'- F/A5EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIR DEPARTMENT OF ENVIRONMENTAL PROTECTIR r, �i� 9: 53 �uu �? 1S15j TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 98 Bridget's Path 3 4/f Centerville. MA 02632 Owner's Name: Katie&Ed Gallagher Owner's Address: Date of Inspection: June 14, 2005 Name of Inspector: (Please Print) Janes M. Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fail Inspector's Signature: Date: June 24, 2005 The system inspector shall su it a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the-time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 y Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 98 Bridget's Path Centerville, MA Owner: Katie&Ed Gallagher Date of Inspection: June 14, 2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken.pipe(s)are replaced obstruction is removed ND explain: 2 i Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 98 Bridzet's Path Centerville, MA Owner: Katie&Ed Gallazher Date of Inspection: June 14, 2005 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 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 -- 1 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 98 BridQet's Path Centerville, MA Owner: Katie&Ed Gallagher Date of Inspection: June 14, 2005 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow ✓ 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No 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. 4 i Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 98 Bridget's Path Centerville, MA Owner: Katie&Ed Galla-aher Date of Inspection: June 14, 200E Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ _ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out? ✓ _ Were all system components, excluding the SAS,located on site? ✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes No ✓ _ 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(3)(b)]. 5 r Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 98 Bridzet's Path Centerville, MA Owner: Katie&Ed Gallagher Date of Inspection: June 14, 2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): n/a Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: n1a Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): apd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Unavailable Was system pumped as part of the inspection(yes or no): 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) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components, date installed(if known)and source of information: Installed on 7129196-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 " Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 98 Bridget's Path Centerville, MA Owner: Katie&Ed Gallagher Date of Inspection: June 14, 2005 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments (on condition of joints,venting, evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 4' Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 Qal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 12" Distance from top of scum to top of outlet tee or baffle: 5" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measurinz stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage. An outlet riser was installed to briniz the cover to 6"below grade. Recommend pumping. 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(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 98 Brideet's Path Centerville, MA Owner: Katie&Ed Gallagher Date of Inspection: June 14, 2005 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Continents(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even 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 D-box was level. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alanns in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): 8 r Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 98 BridQet's Path Centerville, MA Owner: Katie&Ed Gallagher Date of Inspection: June 14, 2005 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: ✓ leaching galleries,number: 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.): The Qallies had 1'of liquid on the bottom. There did not appear to be any signs of failure CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Continents (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 98 Bridzet's Path Centerville, MA Owner: Katie&Ed Gallaher Date of Inspection: June 14, 2005 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. C ,A �ro T B O Ste � Q 1 33 11 a 3°I 1c0 C 3 as 10 v Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 98 Bridget's Path Centerville, MA Owner: Katie&Ed Gallagher Date of Inspection: June 14, 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 20 +/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours maps, the maps were showing approximately 20'+/-to Around water at this site. 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. 11 TOWN OF BARNSTABLE ,T_Or'?: .ON SEWAGE # I 3 VIiLAGc C 'P�1�Q t�`� ASSESSOR'S MAP & LOTS 74- Z3 7 INSTALLER'S NAME&PHONE NO. �� �b��SA b SEPTIC TANK CAPACITY lCZ-rL LEACHING FACII.TTY: (type) �C (size) " ® r NO.OF BEDROOMS BUILDER OR OWNER. S•� T°F' g /L�Ab�vRl7� PERMIT DATE: COMPLIANCE,DATE: t _ Separation Distance Between the: ^ys 1F�.. 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 y Edge of Wetland and Leaching Facility(If any wetlands f 1 exist' �•r within 300 feet o chin facility) * Feet , , s by -'rh- /7� M� �- Furnished Fw• �y q ie>•r 't zs �t z... y. ..► 4 ASSESSORS MAP No-, �°1 0 40 .00 No. �� �� PARcaNa �• Fee 5,?I THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01pplic Lion for Migo$o.Y *pgtem Comaruction 3pCrmit Application is hereby made for a Permit to Construct( )or Repair(x )an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. 98 Bridgets Path Scott & Joanne Howard Centerville Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. W.E. Robinson Septic P.O. Box 1089 Type of Building: Dwelling No.of Bedrooms 4 Garbage Grinder(not Other Type of Building No. of Persons Showers( . ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil sand Nature of Repairs or Alterations(Answer when applicable) install a d-box & 4 H 2 0 stonepacked gallies Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Boar of ea%h. Signed � Date ZO Application Approved by - Application Disapproved for the following reasons Permit No./ '°�✓�.�_� Date Issued 7''l4 ��i� 40.00 No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS x ` Application for Migonl 6potem C ngtruction Permit Application is hereby made for a Permit to Construct( )or Repair(x )an On-site Sewage Disposal System at: F, Location Address or Lot No. Owner's Name,Address and Tel.No. 98 Brdgets Path Scott & Joanne Howard Centerville InsWI.e ',s,N RoblrisonelSeptic Designer's Name,Address and Tel.No. PP�J.��0; Box 1089 Type of Building: Dwelling No.of Bedrooms 4 Garbage Grinder(n�j Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design.Flow gallons per day. Calculated daily flow gallons. Plan' Date Number of sheets Revision Date Title Description of Soil sand Natu>�e of Repairs or Iterations(Answer when applicable) install a d—box & 4 H2O sLonepackea gallies Date last inspected: .- Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Boar of ealth. Signed Date �7 Application Approved by / Application Disapproved for the following reasons Permit No.� .,;��,� Date Issued "'�4- � THE COMMONWEALTH OF MASSACHUSETTS,! PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACH,QSETTS r Certificate of Compliance - w THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced(X )on by ,,W.E. Robinson Septic for Howard as 98 $ridgets Path Centerville has been constructed in accordance with the provisions'of Title 5 and the for Disposal System Construction Permit No. dated Use of this system is conditioned on compliance with the provisions set fort low: No.Z&" .� Fee 40.00 Howard THE COMMONWEALTH OF MASSACHUSETTS E PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS migo!w *pgtem Cott!5truction Permit Permission is hereby granted to W.E. Ioi �neon Septic to construct( )repair( X)an On-site Sewage System located at 98 Rr.idgAi-c Path cent enrille and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within two years of the date below. Date: � r Approved b _v i i CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) I, hereby certify that the application for disposal works construction permit signed by me dated concerning the property located at �` r meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. i, ` Q SIGNED: DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. i 4`1 �U- 1 T ION° Y 75 E /AGE PERMIT N0. 77 VILLAGE I IN L, Rfsc NAME i ADDR � t • f IUII R OR OW E DATE PERMIT ISSUED ��,f �•_ �� DATE COMPLIANCE ISSUED 17f z '�6 NoFIMB....407:." .............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........................A liratiou for Uispooal Vork,5 Tomitrurtivit Prrutit V Application is hereby made for a Permit ermit to Construct ( —)'or Repair an Individual Sewage Disposal System at: ..........................................ram Z 7............... .............. 7..............7��.................. ..... .7. uns 0 -Address / ','-Lot No X........................................... ........................ .......Z.-min;..... ......... e Address ........... e ...:=................. .................................................................................................. ......)> Is aller Address Type_ of Building Size Lot./5j .. ...Sq. feet U Dwelling—No. of Bedrooms..................7........................Expansion Attic Garbage Grinder P4 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria P4 Other fixtures ....................................... -1 < 0,---------------------------------------------------------------------------------*'*'**--------------- Design Flow.........IZ5�............:............gallons pep per day. Total daily flow-----........_ .............gallons. 1:4 Septic Tank—Liquid capacity.ZOO�"-.gallons Length Width..11.6.ne g�.. Diameter................ Depth..gv-`�..P. Disposal Trench—No--------------------- Width.................... Total Length.. .......... Total leaching area....................sq. f t. ...-7- Tot Seepage Pit No......--_./--------- Diameter...../ 2e��Cl)epth below inlet...j Z&..).sq. ft. Other Distribution box Dosing tank Percolation Test Results Performed by.....?Ce............... ........ .... ............ Date..//." ..z. . _i'5� ......... .. I` ......... ------ Test Pit No. Len:k....minutes per inch Depth of Test Pit...... /.# VDepth to ground water............ Test Pit No. 2................minutes per inch Depth of Test Pit------.._........... Depth to ground water.............--.......-- P4 .....................................................................................:.....................................................*-----------0 Description of Soil-- ....... ......... w - S.�z... sir � 1 -- ... ...... .............57;?54- .......................................... ........... - ---- ........................................................................................................... .................................................. ---------------- .............. U Nature of Repairs or Alterations—Answer when applicable-............................................................................................... ..................................................................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TL IT�I-E 5 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. ... ..................... ............ Signeo .................... Date Application Approved By --...... -7-f ......... Date Application Disapproved for the following reasons:................................................................................................................ ......................................................................................................................................................................................................... Date PermitNo......................................................... Issued_.............. Date -s. N� ............ THE,COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH /................ ........................................OF......... ,�Vvftrativu for UWposal Works Toustrurtion Famit Applicatiori is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: ,:- ' 1_7 ................ .......#... ............. ........................................................................ ...... L Address or Lot No ........ .......... S 0 er Address ...........Aid ........ ..... L.-V.<4... .................. ..........................................................0....................................... 'installer Address Type of Building Size Lot./_�/..7:�_6Sq. feet Dwelling—No. of Bedrooms..................5....... Garbage Grinder ( ) U .......................Expansion Attic Other—Type of Building ............................ No. of persons............................ Showers Cafeteria ( ) Otherfixtures ......................... ..........,�f 'V­........**----------------------------------------------------­------------------------*......... ......................... erson-;i&—day. Total daily Design Flow...../ ________________gallons flow......... 2e..................gallons. 1:4 Septic Tank—Liquid capacity,/�,�gallons Length._—'-"—.6... Width..1'_ -". ... Diameter................ Depth.�i��_ Disposal Trench—No..................... Width.................... Total Length.._................. Total leaching area....................sq. ft. Seepage Pit No......`............ Diameter_/!'t—r... Depth below inlet_ . &_iac: Tot )etc %4..Jn-_--Isq. ft. Other Distribution box Dosing tank Percolation Test Results Performed' by...__... ........ .............. Date ' ......_... Test Pit No. L��....minutes per inch Depth of Test Pit... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit........_........_.. Depth to ground water.._.._......_........... .......................................................................... ............................................................................... 0 Description.of Soil....0.....P.........21,,.e., ...........0! ............................ ........................... ..... .7......................................................... .............................................................................................................................. ......................................................................... U Nature of Repairs or Alterations—Answer when applicable.............I.................................................................................. .................................................................................................................7---------............................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T I T 1 5 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. Sign "A ..........;......................................................................... .......................... Date Application Approved By....... ... .... .......V.f ...... .......... ..../. . ....# Date Application Disapproved for the following reasons:................................................................................................................ - ---------------------------*----------------*................................0........................................................................................................................... Date PermitNo........................................................ Issued...................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......... .. ........0 F............ ............................................... Trrtffirate of Taniptiattrr THIS IS TO OT)MFYK� hat the Indivioual Sewage Disposal System constructed or Repaired ............. .......... ------- ......A..... ... ZY.�.......................... ------------- by-.::::......... ..............at..­,4�4"4 ............. ...... A, ZZ has been.installed in accordance with the provisions of T, 5 of The State Sanitary Code as desEribed in the application for Disposal Works Construction Permit No---- ............... dated------&tA'_"74---1v................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. . DATE......../.............................0...................................... Inspector....__ .... ... . ........... _il_�--- -------- THE COMMONWEALTH OF MASSACHUSETTS BOARD C 1 OF HEALTH 7 _1 . ..........OF........... ................. No..........7... ...... FEE... ................. Permission is hereby granted---..-.---=•-. = -------------------------•-------------............-•-•...........-------•- to Construct (I_f 4 7orRepa1Zr ,( an Individual e I sV------S--y- t , � Street ;M ............................................... ............... 712' as shown on the application for Disposal Works Construction Permit�No... ef Dated.... .............................. .......Ode? ✓ 4. ------- ------­---------- Board of Health DATE......I......................................................................... FORM 1255 HOBBS & WARREN. INC., PUBLISHERS WPT`r &rr-t4� S�`' Oi." 'f,a 4',rf r� �,.' s .,. "�`' % ;. 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EXISTING .SPOT :ELEVATIONS O,A . - , Y.: t EXI_SttNG CONTOl1'R 0 _ - - - z, "FI.NIS EtD SROT E:LEVATION:S 0.0 FINISHED c.oNTouR o PR�POS�D, .PLOT PLAN' . . . � Y �PPROVEO= QOARD GF HEALTH Y� /-c isT t3�F , MASS. �� . I °gym; .:D�XTE a AGENT;. .1ar `.27 - � 2/I9C.''7.�5_ r9T1 T . 1r R. �/ O �lE, ill'. INC RLS 5 ��' h. I CERTIFY : TH'AT� TFiE PROPOSED ,' , "�.'g,Ull�O�'W""' t Wt . THIS, PLAN ' I348 Rou'rE 13.4c r CONfJ�Ma,' TO THE ZONING,: LAWS EAST DENIMS , M��.,s s -.- � F� �r�-� s C-)g .:MASS DATE, �0 30 - S C A L C �` 3-. - , �—. _ �4 as 1N J fw .— , >�, i _� / . r/T ;_ JOB `NQ< � '. 3 3 CT lEtd T s �'' _ l.- -- I F S x f ` ATE i, a � ul`' T �:fjF _ LA: D 'SURVEYC)R (; .'. Ei1( �G%��_ NE:c T �_ Gf _Z__ ..„, A •wiry. rA S01L TEST i( 'JER1" ELEVATIONS NOTES: DATE,.'OF S:OIL .--TEST �o %� ,8 INVERT AT BUILDL NG 0 .r. .FT ALL WORKMANSHIP AND :MATERIALS WITNESSED` BY ` �' 'S IN' ET Sc?TIC' TAN�i 070 FT SHALL CONFORM TO.: D E Q.E T:ITLE 5 F ATI' A, , 1 OUTLET .SEPTIC: TAN;!: 6: FT A.ND THE TOWN OF r7.4.4�r5rF�f! ULES. w PERCOL ON R :TE MIN.'/INCW AND .- REGULATIONS FDR SUBSURFACE OBSERVATI°ON HOLE I. OBSERVATION_ HOLE 2 JNLET DISTRIEUTION BOX, 9 .FT. ELE VAT LON E L E.VATION OUTLET :DISTRIBUTION _BOX r a FT, I =. o F INLET LEACHING PI,T `� T. DISPOSAL rc 000 o.sa- - BOTTOM LEACHING. PIT 90.o FT. lam° DESIGN :CALCULATIONS NUMBER OF.. BEDROOMS ... . . . . I. n:o GARBAGE DISPOSAL UNt 1 TOTAL ESTIMW;ED FLO'.il (1L_GAL./BR:IDAY x�' BR.)... 3�_ GAL .YDAY REQUIRED SEPTIC TANK CAPACITY. . .. . . . . . . . ..,... . . GAL. /o a r� GAL., ACTUAL. SIZE OF SEPTIC TANK TO BE INSTALLED.`: LEACHING AREA REQUIREMENTS. ✓�� �` g SIDE . WALL AR:EQ 2 y. GAL./S.F BOTTOM AREA=:L GAL:/S F LEACHING CAPACITY (,BOTTOM+;SIDEWALL ).. ..:. .. . .: . ¢ - GAL. , 3. � RESERVE LEACHING CAPACITY. . 7 GAL. 2 p r7 M/". TOP OF FOUND. , ELEV. /oo /d F�, �'�;��: CONCRETE 4" `.SCH. 40 CLEAN SAND COVERS PVC PIPE MIN, PITCH r—CONCRETE COVER: I/8 PER' FT 2 /o MIN:. PITCH. ���MC s� t: ,r 12 •MAX . ,. o�'� r, O RICHARD a N tj ; — 9...: . RSD ,.R B JAM FLW LI o'HEARN . ASHED> . TONE nw.zxeit I. ST 4 CAST IRON , :: _ Sq YR.\� `. : . PIPE MIN. PITCH- a o w a WASHED STONE 1/4 . ,PER :FT. _ [}I T _ -- :.. .. S.. _o PRECAST _ LEACH:ING.. a :..; GAW. +� - L • , .. .. EPTI ., . . r. r` . r _. _ r•, , 190 HEARN- INC RLS : � 5i TA.N K.... _ G .1`� MAIN STAY RT�E 2-B , ems_ .-_ _ . _.. .. s.. _ :.-. ,._ ,.,, s _I y .,. „- ., w, ...-: _, _... i. - `F vim}` a .. ,<_5 GROUND --�WA1'ER. ,•TABL•llv PRO. LE n. -, _ .A .� ......r. r •. ... ` y . JOBtNO CLIENT L,. G C.� S .S�S,T. _ E ACE � , 1: ,. . ... . . } j F .r .: .. r. .......,. •, �. .... � F .. 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