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HomeMy WebLinkAbout0029 BUCKSKIN PATH - Health 29 Buckskin Path, Centerville A— 170. 01 5 UPC V534 No.2-153COR , kASTINGB.UN i TOWN OF BARNSTABLE ypFTHf T�� �.Q ♦� OFFICE OF DA"STAM s BOARD OF HEALTH rare i639. � ' 367 MAIN STREET 'EDM�Y� HYANNIS, MASS.02601 Januaryl5, 1998 Nepoleon B. Triplett 29 Buckskin Path Centerville, MA 02632 Dear Mr. Triplett: You are granted an extension of time, until June 15, 1998, to install a replacement septic system at 29 Buckskin Path, Centerville, Massachusetts. The extension is granted because you stated you will not be living in this dwelling for several months, from December 28, 1997 until about April 7, 1998. You are therefore ordered to hire a licensed septic system installer to construct a replacement onsite sewage disposal system on or before June 15, 1998. PER ORDER OF THE BOARD OF HEALTH ,�GRaSf, IBCSus R.S. Chairman Board of Health Town of Barnstable SGR/bcs triplett i �Q Dt�, Is( t 9 q S RcC�t►VED ►.E�-r-t`R -r-b4o m y ov TZ c Sranc SysTE-M aN My � RWP-XN-►-Ly HAD A JOLOWNt ►V--j 105pMr)aA.) -CA NKs 1 �j AKJI'IQ, ri 0,Q 6f- THC RE--at- CSTA-rC l.f sT-fn a p nn y Norte E- Ntl WE NAVE- N enf"t, �C�ERi ENL'C� A QRo�3t,E M � AWL( KIND Wi TP THIS S ,51-EM BUT' CO P i L E 711C (fRCvND ce)AS uG crj �t.tmQ� tU G I 'C�IOc�'N T I v l.D uST Gc� AN E: .D A O D � PAD AG. RCADy '?Cc.EfvCt7 S�ME�3�D5 � MAD '�?E1C t3a7STE.l FRO r-1 SFVE-P--A 4 C.om PA>t1I C S W-MO-t1010 oP 1?T l pci kU G' TREt Sq a Tv�N yoc)!R Dcr. ©R-I>E-fc i�J c mE ..b CgD en-p 4q L4.a f/*i iV I� ��s rwi7'1{ Rt�LACt;M1< Nr �SE�oR.E 3o 'AAy�. N Av t co v- 7TJc-1Z k-rS I AN\ C7N Q u C57T N C AN) EXT�NTt ory O� Ttl E &)RP . a Ki.-A (=oR- a NEARING oA)Ti L I LPN� yov _ you2s Sul, TOWN OF BARNSTABLE ypi THE t�„Q'�♦o OFFICE OF i DAMSTAn s BOARD OF HEALTH N"a i639' 367 MAIN STREET 'EO Y�Y HYANNIS, MASS.02601 Januaryl5, 1998 Nepoleon B. Triplett 29 Buckskin Path Centerville, MA 02632 Dear Mr. Triplett: You are granted an extension of time, until June 15, 1998, to install a replacement septic system at 29 Buckskin Path, Centerville, Massachusetts. The extension is granted because you stated you will not be living in this dwelling for several months, from December 28, 1997 until about April 7, 1998. You are therefore ordered to hire a licensed septic system installer to construct a replacement onsite sewage disposal system on or before June 15, 1998. PER ORDER OF THE BOARD OF HEALTH Su� 1�L GRal, R.S. Chairman Board of Health Town of Barnstable SGR/bcs triplett i �Ft Town of Barnstable Department of Health, Safety, and Environmental Services Public Health Division 1a 9. 367 Main Street, Hyannis MA 02601 0 RFD MA'S A Office: 508-790-6265 Thomas A. McKean, RS, CHO FAX: 508-790-6304 Director of Public Health Mr. Triplett December 2, 1995 29 Buckskin Path, Centerville, MA 02632 ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE, TITLE 5. The septic system owned by you located at 29 Buckskin Path, Centerville was inspected on November 20, 1997, by John Graci, a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • The liquid depth in the cesspool was less than 6" below invert • The static level in the distribution box was above the outlet invert due to an overloaded or clogged cesspool You are directed to hire a licensed Town of Barnstable septic system installer to submit a sketch diagram of a proposed system to the Town of Barnstable Health Division Office (Town Hall, 367 Main Street, Hyannis)that will bring the septic system into compliance with 310 CMR 15.00, The State Environmental Code, Title 5 within (14) fourteen days of receipt of this notice. You are also directed to bring the septic system into compliance within thirty (30) days of receipt of this order letter. You are further directed to maintain the system by hiring a licensed septage hauler to pump the septic system to prevent discharge of sewage or effluent into the buildings, onto the surface of the ground, or in to surface waters. Any person aggrieved by any order issued by the local approval authority may appeal to �. any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER O OARD OF HEALTH I mas A. McKean, R.S., C.H.O. Agent of the Board of Health q\hea1th\dbfi1es\tit1e5i.doc No. 1 4/ '��� Fee �,d THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for Migpogal *pgtem Congtruction i3ermit Application for a Permit to Construct( )Repair(Xupgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. C d A-' VQ \ Owner's Name,Address and Tel.No. Assessor's Map/Parcel V -�C,..01 S IP Installer's Name,Address,and Tel.No. J Designer's Name,Address and Tel.No. Rod9-(,r koo eA5 20 0^X+C V l2ua d N- A o o1's oaio() Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 33 gallons per day. Calculated daily flow —3q!l gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank I Gam.. Type of S.A.S. �'�--- Description of Soil .cs--Wy�.D Nature of Repairs or Alterations(Answer when applicable) V-5-v ^6rD S+T — 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 nd not to place the system in operation until a Certifi- cate of Compliance has bee oar ealt Q Signed Date CJ Application Approved by % Date ! Application Disapproved for the f owing reasons Permit No. Date Issued K; } Y L Y' No. Fee j f THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: �/ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pplication for Mtgozaf &p$tem CZon.5trurtton Permit Application for a Permit to Construct( )Repair(v/�upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.acA, C �A—, Il4t Owner's Name,Address and Tel.No. cv� C>ettiz t�t.-rZ_ Y kV.-TY I Assessor's Map/Parcel '"�t7.. U) Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 2U �X4 11UK( A V)V) 6D Type.of Building: Dwelling No.of Bedrooms Lot Size sq.ft. <• Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 33 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. ` tk CGtt L t �t-- Description of Soil • S"A✓�D V n Nature of Repairs or Alterations(Answer when applicable) V S, C c� P is I a, 7Z:r4^14 t i ru To q2 C.v q l 's Tyr-,-" Date last inspected: J 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 nd not to place the system in operation until a Certifi- cate of Compliance has been-issued-by oar ,.Y �ealth. Signed Date Application Approved by Date ( Application Disapproved for the f owing reasons Permit No. Date Issued - -- - ————————————---- THE _— _— --=—==--=---= _ - THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TOACERTIYY,-that theQa-site�Sewa e�Disposal System Constructed( ) Repaired( )Upgraded (t.� Abandoned( )by at t,,1 C lC5 1 Vl f2al 4-V) V ,- I �'"-G been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. rg- 0 dated Installer Designer The issuance of thins permit sh 11 Ve construed as a guarantee that the system will function as designed. Date ,�,� � Inspector_ No. Fee THE COMMONWEALTH OF MASSACHUSETTS ,F PUBLIC HEALTH DIVISION - BARNSTABLEa MASSACHUSETTS Mi5po-qar *pgtem Construction Permit Permission is hereby ranted to Construct( )Repair( 61 pgrade( )Abandon( ) System located at Zq �5 W C k 5 \V1 ye`� t t V V I I L- 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. Provided: Construction must be completed within three years of the date of this permit. Date: J - © " / 'b - Approved by i . i.✓, 4 1019197 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITI OUT ENGINEERED PLANS) I, d� e,A 5 , hereby certify that the application for disposal works construction permit signed by me dated T ,concerning the property located at 2 �`^G V-5�t VA 9'0 -h meets all of the following criteria: " . There are no wetlands located within I oo feet of the proposed leaching facility �. There are no private wells within 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed 'there are no variances requested or needed. If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the proposed leaching facility will pstt be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation. Please complete the following: 2 A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) �¢�? I3)Observed Groundwater Table Elevation(according to Health.Division well map) DAT3 SIGNED: 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 plran, this plan should be submitted). q:health folder:Bert TOWN OF BARNSTABLE ' LOCATION SEWAGE * . VILLAGE ASSESSOR'S MAP & LOT 0 INSTALLER'S NAME&PHONE NO. PA i SEPTIC TANK CAPACPTY %,Y\� ( LEACHING FACILITY: (type) 11 �(size) NO.OF BEDROOMS 2, BUILDER OR OWNER —TtZ,� �— PERMITDATE: v -10 '-�I.COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by r { /3 3- 6 �1Ne Town of Barnstable Department of Health, Safety, and Environmental Services rrsrneLe ; Public Health Division ,'63 367 Main Street, Hyannis MA 02601 Office: 508-790-6265 Thomas A. McKean, RS, CHO FAX: 508-790-6304 Director of Public Health Mr. Triplett December 2, 1995 29 Buckskin Path, Centerville, MA 02632 ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE, TITLE 5. The septic system owned by you located at 29 Buckskin Path, Centerville was inspected on November 20, 1997, by John Graci, a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • The liquid depth in the cesspool was less than 6" below invert • The static level in the distribution box was above the outlet invert due to an overloaded or clogged cesspool You are directed to hire a licensed Town of Barnstable septic system installer to submit a sketch diagram of a proposed system to the Town of Barnstable Health Division Office (Town Hall, 367 Main Street, Hyannis)that will bring the septic system into compliance with 310 CMR 15.00, The State Environmental Code, Title 5 within (14) fourteen days of receipt of this notice. You are also directed to bring the septic system into compliance within thirty(30) days of receipt of this order letter. You are further directed to maintain the system by hiring a licensed septage hauler to pump the septic system to prevent discharge of sewage or effluent into the buildings, onto the surface of the ground, or in to surface waters. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. ORDER OEJj&JOA RD OF HEALTH as A. McKean, R.S., C.H.O. Agent of the Board of Health gUrealth\dbSles\titleSLdoc Town of Barnstable • Department of Health, Safety, and Environmental Services 9'"M'� r Public Health Division i639. Eo�A 367 Main Street, Hyannis MA 02601 Office: 508-790-6265 Thomas A McKean,RS,CHO FAX: 508-790-6304 Director of Public Health TO: 2�1 a DATE: 97 �Q 6"2Cj�-z ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE, TITLE 5. The septic system owned by you located at Z29 &c s�t%n as inspected Aiw'L01 on by JS ,A (!�reict' , a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • � I��U � ��O 1.)W� �n � � 11..D D 06� �S y1.� �p' You are directed to hire a licensed Town of Barnstable septic system installer to submit a ��2`�O sketch diagram of a proposed system to the Town of Barnstable Health Division Office or �cjse-J (Town Hall, 367 Main Street, Hyannis) that will bring the septic system into compliance with 310 CMR 15.00, The State Environmental Code, Title 5 within (14) fourteen days of receipt of this notice. You are also directed to bring the septic system into compliance within thirty (30) days of receipt of this order letter. You are further directed to maintain the system by hiring a licensed septage hauler to pump the septic system to prevent discharge of sewage or effluent into the buildings, onto the surface of the ground, or in to surface waters. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health gM.WthW1.\it1,5Lda Commonwealth of Massachusetts Executive Office of Envirolunental Affairs Dept. of Environmental Protection Jolui One winter Street' D.L.P. Titlee V Septic Boston Ma. 02108 epti c Inspector IF P.O. Box2119 R 7� Ate—pa-1 Teaticket, MA 02536 WILLIAM F.WELD / (508) 564-6813 Governor ARGEO PAUL CELLUCCI ���, y�l t- �•a/ Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 10 PART A CERTIFICATION W Property Address: 29 Buckskin Path Centerville Address of Owner: 4' TDlyN�F 4 199T Date of Inspection: 11/20/97 (If different) 94Tf4? 40 Name of Inspector: John Graci Triplett �/OfpjgB(�r 1 am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) Company Name, Address and Telephone Number: C+j 9 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 lime 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 This Inspection Is based on criteria defined In Title V Conditional) Passes code 310 CMR 16,303.My findings are of how the system is y performing atthe time of the inspection.My inspection does _ Needs1fur er Evaluation By the Local Approving Authority not Imply anywarrantyor guarantee of the longevity ofthe x Fails septic system and any of Its components useful life. Inspector's Signature: Date: 11120197 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. 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. INSPECTION SUMMARY: Check A, B, C,or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,passes inspection. 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 CoTttpliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or the septic tank,whether or not metal, is cracked, structurally unsound,shows substantial infiltration or exfiltration, or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04127197) One Winter Street is Boston,Massachusetts 02108 a FAX(617)556-1049 a Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 29 Buckskin Path Centerville Owner: Triplett Date of Inspection:W20197 _ Sewage backup or.hreakout or high.static water level observed.in.the distribution box is due to a broken. or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled 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 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 THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and 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 presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other D] SYSTEM FAILS: You must Indicate either"Yes"or"No"as to each of the following: x I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No _c_ Backup of sewage in facility or system component due to an overloaded or clogged SAS or cesspool. x_ Discharge or ponding of effluent to the surface of the ground or surface watery duc to till oveiloaded or clogged cesspool. _X_ SAS is in hydraulic failure. (revised 04127)97I r, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 29 Buckskin Path Centerville Owner: Triplett Date of Inspection:W20197 D]SYSTEM FAILS(continued) Yes No 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 1/2 day flow. x Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped x Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. —X- Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. —x Any portion of a cesspool or privy is within 50 feet of a private water supply well. x 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: 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 X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply _ x the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA) or a mapped Zone 11 of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04727)871 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 29 Buckskin Path Centerville Owner: Triplett Date of Inspection:11120197 Check if the following have been done:YOU must indicate either"Yes"or"No"as to each of the following: _c_ — Pumping information was requested of the owner,occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the 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. x As built plans have been obtained and examined. Note if they are not available with N/A. x — The facility or dwelling was inspected for signs of sewage back-up. x — The system does not receive non-sanitary or industrial waste flow. —x— — The site was inspected for signs of breakout. x All system components,excluding the Soil Absorption System,have been located on the site. x The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge,depth of scum. x The size and location of the Soil Absorption System on the site has been determined based on — — The facility owner(and occupants, d different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is unacceptable)[15.302(3)(b)] pevlaed 04127191J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 29 Buckskin Path Centerville Owner: Triplett Date of Inspection:11120197 FLOW CONDITIONS RESIDENTIAL: Design flow: 0 g•p•d./bedroom for S.A.S. Number of bedrooms: 3 Number of current residents: 2 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings, if available:(last two(2)year usage(gpd): nfa Sump Pump(yes or no): No Last date of occupancy: n1a COMMERCIAL/INDUSTRIAL: Type of establishment: n1a Design flow:0 gallons/day Grease trap present: (yes or no) No Industrial Waste Holding Tank present:(yes or no) No Non-sanitary waste discharged to the Title 5 system:(yes or no) No Water meter readings, if available: nra Last date of occupancy: nra OTHER:(Describe) rda Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System has not been pumped in the last year. System pumped as part of inspection:(yes or no)No If yes,volume pumped:0 gallons Reason for pumping: Na TYPE OF SYSTEM Septic tank/distribution box/soil absorptions system x Single cesspool x Overflow cesspool Privy Shared system(yes or no) ( if yes, attach previous inspection records, if any) I/A Technology etc.Copy of up to date contract? Other: APPROXIMATE AGE of all components,date Installed(If known)and source Information: 1968 Sewage odors detected when arriving at the site: (yes or no) No (revised 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 29 Buckskin Path Centerville Owner: Triplett Date of Inspection:11120197 SEPTIC TANK:_ (locate on site plan) Depth below grade: rda Material of construction:x concreate metal FRP Polyethylene_other(explain) If tank is metal, list age o . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: rda Sludge depth:rda Distance from top of sludge to bottom of outlet tee or baffle: rda Scum thickness:rda Distance from top of scum to top of outlet tee or baffle:We Distance form bottom of scum to bottom of outlet tee or baffle: rda How dimensions were determined: Measured 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.) rda GREASE TRAP: (locate on site plan) Depth below grade: We Material of construction: _concrete_metal_FRP_Polyethylene_other(explain) Dimensions: We Scum thickness:rda Distance from top of scum to top of outlet tee or baffle:Wa Distance from bottom of scum to bottom of outlet tee or baffle: We Date of last pumpingrla 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.) rda BUILDING SEWER: (Locate on site plan) Depth below grade: vw- Material of construction:_cast iron_40 PVC_other(explain) Distance from private water supply well or suction linetown Diameter: 4" Q-1mments: (conditions of joints,venting,evidence of leakage, etc.) (revised 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 29 Buckskin Path Centerville Owner: Triplett Date of Inspection:11120197 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: rda Material of construction:_concrete_metal_FRP_Polyethylene_other(explain) i I , Dimensions: nia Capacity: We gallons Design flow: rda gallons/day Alarm level:_Wa Alarm in working order?_Yes_No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) We DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: nia Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box etc.) rda PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no)No Alarms in working order(yes or no)Yes Comments: (note condition of pump chamber, condition of pumps and appurtenances,etc.) rda (revised 0427197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 29 Buckskin Path Centerville Owner: Triplett Date of Inspection:11120197 SOIL ABSORPTION SYSTEM (SAS):x (locate on site plan, if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: rva Type: leaching pits, number: nia leaching chambers,number:nia leaching galleries, number: nla leaching trenches, number,length: nia leaching fields,number, dimensions:n1a overflow cesspool,number:FxWblock Alternate system: nla Name of Technology:_nia Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) The overflow le past the effective depth of leaching.System Is In hydraulic fallure. CESSPOOLS:x (locate on site plan) Number and configuration: one Depth-top of liquid to inlet invert: t" Depth of solids layer: V Depth of scum layer: 2" Dimensions of cesspool: 6'x6' Materials of construction: block Indication of groundwater: none inflow(cesspool must be pumped as part of inspection) nla Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.) System Is In hydrualic failure. PRIVY: (locate on site plan) Materials of construction: nia Dimensions: nla Depth of solids: nla Comments: (note condition of soil; signs of hydraulic failure,level of ponding,condition of vegetation, etc.) nra (revlaed OA127)971 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 29 Buckskin Path Centerville Triplett 11120197 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) Sin A Q AA is p p CA 3L (revbed04n7197) Page ! of 10 ~ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(contlnued) 29 Buckskin Path Centerville Triplett 11120/97 Depth of groundwater 12, Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers X Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) USGS Maps and Charts (revised0e)27MT► sago 10 of 19