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HomeMy WebLinkAbout0046 GREAT MARSH ROAD - Health 46 Great Marsh Road, Centerville L f IIIh�y� QECVCLp� IIII 3 UPC 12543 ' No. 53LOR �'bsr cQNSJ��c HASTINGS, MN i�,44—t C 9 (� Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 GREAT MARSH RD Property Address LEVINE Owner Owner's Name information is required for CENTERVILLE MA 02632 5/29/13 every page. Cityfrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key Q to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return key. DOUGLAS A BROWN INC _ -- --Company Name-- - --- P.O. BOX 145 Company Address CENTERVILLE MA 02632 'ed0/ Cityrrown State Zip Code 508-420-4534 S14297 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ FA � o ❑ Needs Further Evaluation by the Local Approving Authority In ,spect,W Signature Date --4 The system inspector shall submit a copy of this inspection report to the Approving Auth�y(Bard of Health or DEP)within 30 days of completing this inspection. If the system is a shared*stem or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how he system will perform in the future under the same or different conditions of use. t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts N - Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments. . M 46 GREAT MARSH RD Property Address LEVINE Owner Owner's Name information is required for CENTERVILLE MA 02632 5/29/13 .every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I 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: S.A.S WAS OPENED AND FOUND TO BE EMPTY WITH NO SIGNS OF FAILURE AT TIME OF INSPECTION B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old'or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A Metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 GREAT MARSH RD Property Address LEVINE Owner Owner's Name information is required for CENTERVILLE MA 02632 5/29/13 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System-will- pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y� ❑ -N _❑_ND (Explain below)_ ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety,and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 46 GREAT MARSH RD — Property Address LEVINE Owner Owner's Name information is required for CENTERVILLE MA 02632 5/29/13 . every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 GREAT MARSH RD Property Address LEVI NE Owner Owner's Name information is required for CENTERVILLE MA 02632 5129/13 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less that!5 ppm, provided that no other failure criteria are triggered. A copy of the pnalysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. El ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ 0 the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 GREAT MARSH RD Property Address LEVINE Owner Owner's Name information is required for CENTERVILLE MA 02632 5/29/13 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® 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: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 GREAT MARSH RD . ._. Property Address LEVINE Owner Owner's Name information is required for CENTERVILLE MA 02632 5/29/13 every page. Citylrown State Zip Code Date of Inspection D. System Information Description: ACCORDING TO AS-BUILT SYSTEM CONSISTS OF A 1500 GALLON TANK D-BOX AND-2 500 GAOOLN CHAMBERS Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ❑ No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: 2011--------209 2012---267 Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 l Commonwealth of Massachusetts Title 5 Official Inspection Form_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 6•�'` 46 GREAT MARSH RD Property Address LEVINE Owner Owner's Name information is required for CENTERVILLE MA 02632 5/29/13 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 GREAT MARSH RD Property Address LEVINE Owner Owner's Name information is required for CENTERVILLE MA 02632 5/29/13 every page.. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2000 ACCORDING TO ATTACHED PERMIT Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet - Material of construction: ❑ cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 PER PERMIT Sludge depth: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 46 GREAT MARSH RD - - Property Address LEVINE Owner Owners Name information is required for CENTERVILLE MA 02632 5/29/13 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 - How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): RECOMMEND PUMPING EVERY 2-3 YEARS Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 GREAT MARSH RD - -- -- - - Property Address LEVINE Owner Owner's Name information is required for CENTERVILLE MA 02632' 5/29/13 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): ' Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 GREAT MARSH RD - Property Address LEVINE Owner Owner's Name information is required for CENTERVILLE MA 02632 5/29/13 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes 0 No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Tithe 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 GREAT MARSH RD Property Address LEVINE Owner Owner's Name information is required for CENTERVILLE MA 02632 5/29/13 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ 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.): CHAMBERS WERE EMPTY WITH NO SIGNS OF FAILURE AT TIME OF INSPECTION Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 GREAT MARSH RD Property Address LEVINE Owner Owner's Name information is required for CENTERVILLE MA 02632 5/29/13 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 46 GREAT MARSH RD Property Address LEVINE Owner Owner's Name information is required for CENTERVILLE MA 02632 5/29/13 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 15 of 17 P 9 P Y 9 4 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 46 GREAT MARSH RD - - --- - - Property Address LEVINE Owner Owner's Name information is required for CENTERVILLE MA 02632 5/29/13 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar - -__ -- - -- -- ®-Shallow wells--- - -- - Estimated depth to high ground water: 11.7 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: SEE ATTACHED DOCUMENTATION Completeness Checklist on next page. Before filing this Inspection Report, please see Reportp g t5ins-3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 46 GREAT MARSH RD _. Property Address LEVINE Owner Owner's Name information is required for CENTERVILLE MA 02632 5129/13 every page. City/Town' State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal,System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF B,kM4STABLJE LOCATION L�C �rL cr i 4��'� /is l� t2`I SEWAGE f 2/0,1 VI"i LAGE CL- ' '1 -_ ___ ASSESSOR'S IviA>� & LOT _ — INSTALLER'S NPME&PHONE NO. r SEPTIt- TANK.. CAPACITY - LEACHING FACILUY: (tYPe) n NO. OF BEDROOMS BUTIL,DER OR OWN -U COMPLL4NCE DA 1E: C. PERMIT DA%E: '� Separation Distance Between the: Feet 1,jaximum Adjusted Groundviater Table and Bottom of Leaching Facility private Water Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 2Qo feet of leaching facility) wetlands exist Erige of Wed and and LeachingFacility (If any Fees within 300 feet of leaching facility) Furnished by ih p `l I NOTICE: This Form Js 'J,) Be Used Fc,,r the Repair 4`)f Rdied se0fic Systems Only. C R'T FRCA TON of sIcE T AND APPLICA'T-WON FOR A 13 FDAL WORKS CONS�'IRUMON PER M Obi"'DESTO�� ����� T ♦mill i at?i E. Robinson,5 x ev-eby ce,-Ify tiie appli n-mon for disposal twOO:�� construction petit signed by the dated concerinig the ptope-,,cy located at 46 Great Marsh Rd.. 9 Centerville _ rrte�ts Mowing cratefi a: 0 The failed system is connected to a residential dwelling only. There are no commercial or b si-ile uses associated with the dwelling. The soil is classified as CLASS I and the percolation rate is less IhM or�+>a!to S srdnzzEe;pr;e i73^�-. There are no wetlands within 100 feet of the proposed scpeic SY M—tt There'arc no,private wells ivididn 150 feet of the proposed Septic S}•seetn There is no' increase in flow and/or change in use proposed There are no variances reque—sted or needed- . The b6tzom ou the proposed leaching facility will not be looted leis th.?-n five feet above Lhc ma!do'murn adjusted groundwater table elevation: fA.djust the g: unsd ter table trsirag tlsr fir: .cs method when applicable) <, if the S.?�S. brill be lid with 250 feet of any vegetaaed,x aads.the bot3oxn r, the nnxu ,-d imching facility will not be located less/:`girt fourteen t 141 f-ei above Ll t max' vsr,264 t: d gTc,us--Idivata table elevation, ;Plc comp-lete the fa klowie : To?of Ground Stirface°EievWjo:1 Wsireg GIS 1 =taon y the M-AX. I3i�6 G.51 adiUSI Herat a tsVEE 1 a and B Dweiling i�Ic.of E-edrooms Lot size sq.ft. Garbage Grinder( ; ;;her Tyre of.Building No. of Persons Showers ( } Cafeteria; ) C. t::�ris:t:ires gallons per day. Calculated daily flow galiois.- _r.. is Number of sheets Revision Date _ S>ze c Semi:: �a':c Type of S.A.S. — ofiiGFA-_ C•2.i1G. --- Na .r�.e Of d?epairs c�r: Ite.ataoaas(Answer when applica .e, Title-5 septic system consisting, O- a tank D-box and 2 leach c lumbers lnrl th �tnnP all arnbi d Dat,-last inspected: �.per.�eret: T}:e uncieisigned agrees to ensue ti?e construction and r,.ainte,iance of tiie afore descr;red on-site sewage uispvsai systeri 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 Board of,"lth. Sign �v �. �_- <- ! - Dat ' vi f �� Date Application Approved by_ .. - = - _ t_pplicadon Disapproved for the following re o,s I'eitn.it No. f� Date Issued HE a^.C}FFldMC?MWEALTH OF MASSACHUSE f S Mossiiimi BARNSTABLE, MASS +aCl USE TS ertcf Irate o %'w s 161 TO L_''m' "Y' that-thy_ n-Site.tie'+va'e�rSaOSaI System COnstrucied( )Repaired(h i Upgrade IVirie 1';� rivU r1SOid .�Fgpti .�e �v_tce 'a-done•+ b- 46 Great l!.o.7-sj'1 Hd ; . Centerville has_r en}co-,;uucter-i ii� accordan e L .f i �r1ii.i tC:e provisions O-r�I'iilC aiid the for Disposal System Construction PermitNo.i I -21 dated ---- Tr�t?;.iPr Wra1 1''; « Robirmon r o Designer f _'! r !j` I` +i - r as a guL:LmateC that to syst6 ili function as de ighUd i / P :3suLnce of ... _iCfi:"_.3i al P� oe ro*ist,ue3 l Al _- ;_.__=1%1 �:j•-- -� _�_._____._�____..___._�s____ ��—__.�__._____._ its�0 — gin•- = __ �IIPJI�`i~1�,�EAU E, OF Aa.ASSA��H SE t ±Q rt:rted to Constrict( )Repair(X� )Upgrade( )Abandon( ) g 1i.t, tT; at itia-rsh Hd , Centerville 1 ti1i f1',,Lr: ~ir.tl.. above Application for Disposal System construction Pin7lit.T'l aY, icon reco p_. i f.� yi;tii Ti'if d .C.die G lowhig local,provisions a D_cial conditio;m i I.! - ( �. -:s: lJJrteiti�'i101]must be completed within three aC._ys Oi the date of this pe ftii( , ' ` ` i ( . °4' CroAr o t a IA 70 ,¢CIL- x_g 21 3 a .f No. Fee $5 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zippfication for Diopool 6petem Construction Permit Application for a Permit to Construct( )Repair(x)Upgrade( )Abandon( ) O Complete System O Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 46 Great Marsh Rd.. , Centerville Chris Mossman Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service P 0 Box 1089, Centerville Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) 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 Size of Septic Tank Type of S.A.S. Descripiion of Soil S and. Nature of Repairs or Alterations(Answer when applicable) Title-5 septic system consisting of a tank n—box and 2 lennh nhamhRrg with stone all aredtnd 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 issuedVbytis Poard of lth. Sign Date Application Approved by Date Application Disapproved or the following re o s Permit No. Date Issued No. 7 V � I V- , l �' ,_ w, Fee S 0 FL THE COMMONWEALTH OF MASSACHUSETTS _ Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZppYfcation for Migpaal *pMem.. Construction permit 4 Application for a Permit to Construct( )Repair( X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 46 Great harsh Rd.. , Centerville Chris Mossman Assessor's Map/Parcel i ler's e, d sn and Tel No Designer's Name,Address and Tel.No. m. ��:` o��nson peptic Service s P 0 Box 1089, Centerville Type of Building: ' Dwells No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) t ." Other Type of Building t No. of Persons Showers( ) Cafeteria( ) Other Fixtures / r Design Flow gallons per day.,Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Sand. � " 1 Nature of Repairs or Alterations(Answer when applicable). Title-5 septic system consisting of a tank, D",box and 2 leach chambers with stone all around . 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 is ed b .his oard of e^altli:. Sign `� Date 6'U >�- Application'Approved by Date Application Disapproved for the following re s s Permit No. t�r0 Date Issued , z THE COMMONWEALTH OF MASSACHUSETTS Mossman BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CI✓ ,that to Sew,a a Dis os S stem Constructed( )Repaired(X )Upgraded( ) uu t r ��� on a�pzn �'ervise Abandoned( )by at 46 Great Marsh Rd. , Centerville In has onstructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. at S Wm. E., Robinsonr. Installer Designer I Aa <� The issuance of this permit shall t b'`lc�onstrued as a guarantee that the systdm-will fu�}�}ction asfdesigne�d! Date �i InspectorV f l f9 No-- 1_ -------------------------Fee $50 THE COMMONWEALTH OF MASSACHUSETTS Mossman PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Itopozal 6potem Construction Permit Permission is hereby gr ied to Construct( )Reppair(X )Upgrade( )Abandon( ) System located atb Great Marsh Rd. , Centerville 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:Con cti6nn must be completed within three years of the date of —pee /l Approved Date: �� pp y 1/6/99 ' sr r 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(WITHOUT DESIGNED PLANS) ), W i l l iain E. R 6 bins on,5rnereby certify that the application for disposal works construction permit signed by me dated concerning the property located at 46 Great Marsh Rd.. , Centerville meets all of the following criteria: • The failed system is co to a residential dwelling only. There are no commercial or business uses associated with thi g. The soil is classified as CLASS I and the percolation rate is less than or equal to S minutes per inch. There are no wetlands within 100 feet of the proposed septic system 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 C There at�no variances requested or needed. • The ttom of the proposed leaching facility will 0- be located less than five feet above the ma. mum adjusted groundwater table elevation.' [Adjust the groundwater table using the Frimptor me od when applicable] • If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located lass than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) ' B) G.W.Elevation+the MAX High G.W. Adjustment DIFFERENCE.BETWEEN A and B SIGNED : Lc,, b t-Z�— ✓--L DATE: 7 r6—d [Sketch proposed plan of system on back]. y:health folds cert d G E ! t � 1 Li { ----------------------------------- I i f S'J TOWN OF BARNSTABLE L o C' + LATION�LIG`" •T dam s if t2 SEWAGE # f 0 .� y D VILLAGE �i-s^-> ASSESSOR'S MAP & LOT Z�O 1 /23 INSTALLER'S NAME&PHONE NO. z 1 L SEPTIC TANK CAPACITY /S-0-0 LEACHING FACILITY: (type) oZ".St g (size) I off--2 S-2 I NO.OF BEDROOMS 3 BUILDER OR OWNER n,s s ".d�- PERMITDATE: A" -COMPLIANCE DATE: 6' 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 - � I �- -o� , � R a a`" 3Q , 5 0 � . -. z • � _� �. G TOWN OF BARNSTABLE LOCATION L/l ' v• ' eD"5 if � � SEWAGE # d 0 — .� v 0 ASSESSOR'S MAP & LOT VILLAGE 210. 12 3 INSTALLER'S NAME&PHONE NO. — SEPTIC TANK CAPACITY Sr g �- ( i2--2S-2 LEACHING FACILITY: (type) y �- <- size) NO.OF BEDROOMS 3 I BUILDER OR OWNER PERMITDATE: —a COMPLIANCE DATE: G�t''L' i Separation Distance Between the: Feet Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by i � 0 V -d ` .,_ CO'.%1'.%10"Y"7EALTH OF MASSACHUSETTS _ EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAJR,;, E' DEPARTMENT OF ENVIRONMENTAL PROTECTION ci r ONE Xt'I\TER STREE':'. BOSTO\ MA 0210E (617, 292•5511v �J- TRL DY CO.1 Secre;an ARGEO PALL CELLUCCI DAVID B STP.-'I?S Governor Comzniss:one- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address:46 Great Marsh Rd.. Name of Owner Chris Mossman Centerville Address of Owner: Date of Inspection: L—/y C-0 Name of Inspector:(Please Print)WM. E . Robinson Sr. I am a DEP approved m system inspector rwant to Section 15.340 of Title 5(310 CMR 15.000) cornpanyNae: Wm. E . Robinson Ileptic Service Mailing Address: PO Box 10 9. Centerville , AA Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: 'Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Ihspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to ttre system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS Jut revLsed Page Iof11 n � ati i• ^!ed on Reovded Pane, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) "roperty Address:46 Great Marsh Rd.. , Centerville )Wner: Chris Mossman Date of Inspection: C_w_c— INSPECTION SUMMARY: Check 6)8, C, o/ D: A. �SYSS PASSES: `� 1 have not found an information which indicates that en of the failure conditions described in y y c d 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYS M CONDITIONALLY PASSES: On or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon co pletion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, o, or not determined (Y. N, or NO). Describe basis of determination in all instances. If "not determined', explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20)years prior to the date of the inspection: or the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipets) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipets) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipets). The system will pass inspection if(with approval of the Board of Health): broken pipets) are replaced obstruction is removed i revised 9/2/96 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Icontinued) Property Address:46 Great Marsh "d.. , Centerville owner: Chris Mossman Date of Inspecbon: C. FUR ER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: C nditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the p lic health, safety and the environment. I SY TEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS OT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 21 YSTEM 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 AND 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 supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 31 OTHER revise 9�2�98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 46 Great Marsh "d.. , Centerville Ownw: Chris Mossman Date of Ins on: D. SYSTEM FAILS: You m st indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this etermination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes N Backup of sewage into facility-or system component due to an overloaded orclogged SAS or cesspool. _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet 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. LAR E SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: he following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 11 of a public water supply well) The b ner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office t the Department for further information. revised 9/2/98 Pagr4ofII I • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART B CHECKLIST PTop"Address4( Great Marsh Rd.. , Centerville Owner: Chris Mossman Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No _ Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and-the system has been.receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _ As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. L/ _ The system does not receive non-sanitary or industrial waste flow. e/ _ The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. LZ _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: ✓ _ Existing information. For example, Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) (1.5.302(3)(b)] - _ The facility owner (and occupants,if different from owner) were provided with information on the proper maintanaac."f SubSurface Disposal Systems. ( revised °/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART C SYSTEM INFORMATION •roperty Address: 46 Great Marsh ZLd., Centerville Owrw: Chris Mossman Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: `ISO g.p.d.lbedroom. Number of bedrooms(design): Number of bedrooms (actual): Total DESIGN flow G Number of current residents: Garbage grinder(yes or no): A,v Laundry Iseparate system) (yes or no)A D; If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use (yes or no):/-O Water meter readings, if available (last two year's usage (gpd): 1 999 �8 , 00G gal. Sump Pump(yes or no):A,O 1998 51, 000 gal Lest date of occupancy: COMME CIALIINDUSTRIAL: Type of a tablishment: Design flo : qpd 1 Based on 15.203) Basis of d sign flow Grease tra present: (yes or no)_ Industrial aste Holding Tank present: (yes or no)_ Non-sanita y waste discharged to the Title 5 system: (yes or no)_ Water me er readings,if available: Last dot of occupancy: OTHER ID tribe) 1 Last a of occupancy: GENERAL INFORMATION PUMPING RECORDS and Aource of information: System pu ped as part of inspection: (yes or no)_,�f,d If yes, volume pumped: gallons Reason for pumping: TYPES 0 YSTEM L/ Septic tank/distribution box/soil absorption system Sin le cesspool 9 P Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records;if any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known)and source of information: t�,—1 =• �� L✓u� ts0 ,� Sewage odors detected when arriving at the site: (Yes or no) revised Page 6o111 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) tropertyAddress: 46 Great Marsh d,. , Centerville owner: Chris Mossman Date of Inspection: _/1/0-0 BUILE NG SEWER: (Locate on site plan) Depth low grade:_ Materia of construction:_cast iron_40 PVC_other(explain) Distan a from private water supply well or suction line Diam er Co ents: (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK:_ (locate on site plan) 1 Depth below grade:�/on.rete Material of construction: _metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age_ Is.age confirmed by Certificate of Compliance_ (Yes/No) Dimensions: /— at l O L 6 Sludge depth: 0 i Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: O Distance from top of scum to top of outlet tee or baffle: r 1 Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: ;omments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) /f, '/S O•U Q T.�.�-I r Y s Off — 3S!d GR E TRAP: (locate on site plan) Depth elow grade:_ Materia of construction:_concrete_metal_Fiberglass _Polyethylene_otherlexplain) Dimen ons: Scum ickness: Distan a from top of scum to top of outlet tee or baffle: Dista ce from bottom of scum to bottom of outlet tee or baffle: Date f last pumping: Co ments: (r ommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evi ence of leakage,etc.) L revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM , PART C SYSTEM INFORMATION(continued) 'rop"Address: 46 Greta Marsh Rd.. , Centerville Owner: Chris Mossman Date of Inspection: TIGHT HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth bel w grade:_ Material o construction:_concrete metal_Fiberglass_Polyethylene_other(explain), Dimensi s: Capacit gallons Design ow: gallons/day Alarm resent Alarm I vel: Alarm in working order: Yes_ No Date of revious pumping: Comme is- of (conditi n inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: v (locate on site plan) Depth of liquid level above outlet invert:` Comments: (note if level and distribution is equal, evide of solids carryover, evidence of leakage into or out of box, etc.) - PUMP C AMBER:_ (locate o site plan) Pumps i working order: (Yes or No) Alarms n working order(Yes or No) Comm nts: (note ondition of pump chamber, condition of pumps and appurtenances,etc.) revises 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) NopertyAddress: 46 Great Marsh Rd., Centerville JWner: Chris Mossman Jate of Inspection:0—J/ -o-tP SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) I n b i � f � h i r I a • o t - I l 1 revised 9;2/98 Page 10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'rop"Address: 4.6 Great Marsh rd . , "enterville Owner: Chris Mossman Date of Inspection: r,—c� / SOIL ABSORPTION SYSTEM(SAS):_V (locate on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods) It not located, explain: Type: leaching pits, number:_ leaching chambers,number: — leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of,,p�onding, damp soil, condition of vegetation, etc.) CESS OOLS:_ (locate n site plan) Number a d configuration: Depth-top f liquid to inlet invert: Depth of s lids layer: Depth of sc m layer: Dimensions of cesspool: Materials of construction: Indication o groundwater: in low (cesspool must be pumped as part of inspection) Comments. (note con ition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) c. PRI _ (loc eon site plan) Mater Is of construction: Dimensions: Depth of solids: Com nts: (note ondition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) =ev-ce: Ji L; 7� Pag(9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) top"Address: 46 Greta Marsh } d.. , Centerville OW11 - Chris Mossman Date of Ins on: NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow. Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells ti Estimated Depth to GroundwaterF"A74 Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property. observation hole.basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators. installers Used USGS Data Describe how you established the High Groundwater Elevation. IMust be completed) - x r no r revised 9/2/95 Page Iiorll �J TOWN-OF BARNSTABLE LOCATIO'. SEWAGE # VILLAGE ASSESSO S MAP& LOT/-D 3 6057 INs 7UlP 5'NAME&PHONE NO. / SEPTIC TANK CAPACITY t� rG LEACHING FACILITY: (type) �i OL �/ ) (size) NO.OF BEDROOMS o2 BUILDER R OWNE PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by �� ��� SGµ . 0 � - �9� �`� ' v aio /ate F E B 7 19,9).T BORTOLOTTI CONSTRUCTION, INC. ��� d 765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 I!, 508-771-9399 508-428-8926 FAX: 508-428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 6 PART A CERTIFICATION Property Address: Date of Inspection: Inspecto ' Name: er's Name and Address• CERTIFICATION a I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of inspection. The inspection was per- formed balpd on my training and experience in the proper function and maintenance of on-site sewage disposal stems. The System: Passes Conditionally Passes Needs Further Ev tion By the Local Aproving Authority Fails Inspector's Signature: Date: The System Inspector shall submit copy of this inspection report to the Approving authority within thir- ty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional, office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION C 1MMARV• A)SYST PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system,upon comple- tion of the replacement or repair,passes inspection. Indicate yes,nor,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,cracked,structurally unsound, shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of The Board of Health): -1 - Tj 9 !"""; SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM i. . ry�Nrx3!i PART A CERTIFICATION(continued) Broken pipe(s)replaced Obstruction is removed Distribution Box is levelled or replaced The System required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of The Board of Health): Broken pipe(s)are replaced Obstruction is removed C)FURTHER EVALUATION IS REQUIRED BY THE BOARD'OFHEALTH: 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 FUNCTION- ING 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 water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is with a Zone I of a public water supply 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 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 the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than.5 ppm. D)SYSTEM FAELS: 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. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent 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 clog- ged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped -2- } SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A r CERTIFICATION (continued) l° Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 Feet of a private water supply well. Any portion of:a cesspool or privy is less than 100 Feet but greater than 50 Feet 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: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 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: The system is within 400 Feet of a surface drinking water supply The system is within 200 Feet of a tributary to a surface drinking water supply The system is located in a nitrogen sensitive area Interim Wellhead Protection Area (IWPA)or a mapped Zone II of a public water supply well. The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: F &Pumping information was requested of the owner,occupant,and Board of Health. None of the system components have been pumped for atleast two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. �As-built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. ✓The site was inspected for signs of breakout. ✓All system components,excluding the Soil Absorption System,have been located on site. __Ae!:1Me septic tank manholes were uncovered,opened,and the interior of the septic tank was in- spected for condition of baffles or tees, material of construction,dimensions,depth of liquid, th of sludge,depth of scum. f/The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. -3- L SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B i CHECKLIST(continued) _ZThe facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION •' - FLOW CONDITIONS RES •t� Design Flow:---23y gallons Number of Bedrooms: '`? Num er of Current Residents: � Garbage Grinder: Laundry Connected To System: Seasonal Use: Water Meter Readings,if avvp'lable: Last Date of Occupancy: (,/, oiri COMMERCIAIANDUSTRIAL: Type of Establishment: Design Flow: gallons/day Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS and source of informs 'on: � (1//L System Pumped as part of inspection: 6 If yes,volume pumped: gallons Reason for pumping: TYPE OF SYSTEM: Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy §hared System(If ye attach previous inspection r ords, if any) -'Other(explain): � APPROXEKATE AGE of all components,date installed(if known)and source of information: 12 Sewage odors detected when arrivin at the site:. A JV/) -4- I A. ,Z gf SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C t GENERAL INFORMATION (continued) SEPTIC TANK: Depth below grade: /a „ Material of Construction: concrete metal FRP Other (explain) — Dimisions: o X S Sludge Depth: Scum Thickness: O � Distance from top of sludge to bottom of outlet tee or battle:_ ;3 j Distance from bottom of scum to bottom of outlet tee or baffle: Comments:(recommendation for pumping;condition of inlet and outlet tees or baffles,depth of liquid 1 el in lion too ptlet invert,structural integrity,evidence of leakage,a c.) all a•r GREASE TRAP:�d Depth Below Grade: Material of Construction: concrete metal FRP Other (explain) — — — — Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle: 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.) TIGHT OR HOLDING TANK: Depth Below Grade: Material of Construction:—concrete- metal—FRPOther(explain)— — i. Dimensions: Capacity: gallons Design Flow: Qallons/day Alarm Level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) PUMP CHAMBER: Pump is in working order: Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) -5- r G „ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (con(inued) lY SOIL ABSORPTION SYSTEM(SAS): (Locate on'site plan, if possible;excavation not required,but may be approximated by non-intrusive methods). If not determined to be present,explain: Type: Leaching pits,number: Leaching chambers, number: Leaching galleries,number: Leaching trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number: Comm ts: (note condition of soil,si ns of h raulip failure level of pondin4,condition of vegetation, etc.) ii If - CESSPOOLS: Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of Cesspool: Materials of construction: Indication of groundwater: Inflow(cesspool must be pumped as part of inspection) Comments:(note condition of soilk,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) PRIVY:,, Materials of construction: tructio Dimensions: Depth of Solids: Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) -6- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 1 SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. o p 1 Pa P 7, , i DEPTH TO GROUNDWATER: / Depth to groundwater: /4) Feet Me od of Deterrnipation�or Approximation: /rx/ Y'®!7d �J• W � s -7- : 6�k M-- -r-A. x 1Srifr h'�- 07' 65r t3� (fNsl'�.�'Q L. - ' r lot ry _ 14,4 CIL $� ay lot IH ; s- / 1 ,Z(o SeA a16 - / a3 f No..... ....... Fizic THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Aoqinh� C................................ VYS ----164044­.�_.. ..............OF............. Application for 13isposal 16ork.5 (fintstrurtilatt Prrutit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: . ....S.._.....f.......S......6......*........6.._._._.#_._._7--------*--1--#- ArS.7- - ---- l.9 /...........................,................o.rl...lL..o.z ..z....6..... . .. .... ......... ...................Z•C� Location --------- 1 ............ L . .�A . . .e .. .....e . rr ....Owner Address ................................................zm Ora............................... .................................................................................................. Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.... ..Expansion Attic Garbage Grinder ( ) 04 Other—Type of Building ............................ No. of persons............................. Showers Cafeteria ( ) 04 Other fixtures ------------------------------------------------- ----- ------ --------- --- ----- ----- ---- ------ -------- -Design Flow........�.. ... ...... gallons per person per-day.--iotal-'da-i'ly C4 Septic,Tank—Liquid capacO.' W r._..........gallons. Length................ Width................ Diameter......_._.__.... Depth.............--. Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..-//..-O.�oi,.,Vi-airieter.J"lp.......... Depth below inlet.................... Total leaching area..................sq. f t. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................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........................................ �4 J-'�A'Y----------&.............../-------------------------------------------------------------------------------------­-------- U ............o.......... ....................................... ............... .......:......................................................................................... W -----------------------------------------------------------------------------------------------------------------------------------------------------------------7­-----------------7.................. 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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued b the board �health. 77��y __,board n 10-0./-7 Signed----X..... ..... ....................... -------------------------------- Date ........................... .......................... ......................................-- Dace Application Approved By. ------ --- /0 - Ao/-7 Application Disapproved for he following re , ns. ........................................................................................... .- .............. ........................................................................................................................................................................................................ Y .. Date Permit No P ' .. .....................I......... Issued...................................................----- ......... Date ------------__--------------- --- ----------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH g,,,;z,_. ..................OF.... A pliralia-ti fOr Biapogal 13*rkfi Toustrurtivxt nuts# Application is hereby made for a Permit to Construct ( ) or..Repair ( ) an Individual Sewage Disposal System at j ......'�....t........... �I '! rr ?�1r +- °. C... rp f„r_.� F. t f p. �„ R- r Location.-anon Address or Lot No ......................... .:4. A .. } ` ... ......... I ... .�G.!: r .r4, F Owner r •Address ..e f. !.. Installer ?a?.................................... .................................................. ......... ........ .................. � Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.........4'.'. .../T '*4' ..Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons--__.____--.---------___-__- Showers ( ) — Cafeteria ( ) Other fixtures ........................................ W Design -Flow .....,f�' gallons per person,per day. Total daily flow------ a L 1 ........... ........gallons. W Septic Tani. Liquid capacity'_~'.`....:..gallons Length................ Width................ Diameter................ Depth............... . x Disposal Trench'=No.. ...... Width.................... Total Length.................... Total leaching area............__....... sq. ft. Seepage Pit No.-..,.'. �.3___ t meter..:_ -:_._......:: Depth below inlet.................... Total leaching area....................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed bv................. _..._._.... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water--.-__-_-------_------ (1tq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......................... ..............-.....................................................................----••......................................................... 0 Description of Soil................................................. --------------------------•-----...-----....----------...-----------------------•-•••-•- _.V ------------------------------------•------------------------••-•--••-•--••---••-••...... W 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 Article xI 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 jpf health C �. i ✓'� d Signed iC S.. ...• Date Application Approved BY---...:y%' ._ .g „�!-.,_.r.... = :.. --------------- f-c Date Application Disapproved fort ae following Fens ns:...-•----------------------------------•---•-----------._._._......-----------•-•----....--••---•---•-------.... - ..--••••-•••••---•-•..••••--.•----•..............•------------•-••--------------•--..•-•-•--•-•------•-----••-•--------•-•-•••------•----•-----------------........_................................... Date Permit No......... 211.`T_/---`...........•.................. Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS i BOARD OF HEALTH ................... OF �.� Y} 8. - ....::.: . rjc ........ THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) _ Y ..... 'f ............ :..!...... .. ---•-•--............•----......----........ Installer at...................... ------ 'I".E_ i`" sue" r.r ,�'j,•sLx;/ .. r ��-a%-' .�j , has been`installed in accordance with the prov 151ons of <�rticle AI of The State Sanitary Code as described.m Xhe application for Disposal Works Construction Permit No..... r_,z_ '----------------- dated---------------------_....................... _._. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTI N SATISFACTORY. DA ......... Inspector.... --•--..... ..................2....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No -• •- Permission is hereby'granted---, 1� .�r . --------••-•--••--------•-- ----- ...- . to Constru t'2ti ) or-Rear.._( )Na f�izd idual$SS�Oage i?ispOsal r5ystemj�' at No......... ...... ....... . ..... •----•...... ... Street ............. 1 t as shown on the application for Disposal `Forks Construction Permit No;.................... Dated............................................ d cal l L t :. ;., --(o ti t DATE........ FORM 1255 HOBBS &WARREN, INC., PUBLISHERS ..