Loading...
HomeMy WebLinkAbout0046 HEATHER LANE - Health (3) 46 Heather Lane, CEntervil . 1 0. 002 I I as � � UPC 17534 No.2_153COR hASTINOS.MN I II . I i • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Heather Lane Property Address A Monica Kicklighter Owner Owner's Name information is Centerville, Ma. �M Ma. 02632 April 23,2016 required for every page. Citylrown State Zip Code Date of Inspection tr n Inspection results must be submitted on this form.Inspection forms may not be altered in any a way. Please see completeness checklist at the end of the form. I Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Thomas Roux use the return Name of Inspector key. _Q Company Name 89 Mayflower Lane Company Address East Wareham Ma. 02538 City/Town State Zip Code 774-678-9066 S14531 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 6(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Da 'g Disposal System•Page 1 of 17 4 a*d V6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 Heather Lane Property Address Monica Kicklighter Owner Owner's Name information is Centerville, Ma. Ma. 02632 April 23 2016 required for every p page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. 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 ass inspection if it is structural) sound not leaking and if a Certificate of p P P ,Y g Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND Explain below): ` t5ins-3113 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 Heather Lane Property Address Monica Kicklighter Owner Owner's Name information is Centerville Ma. Ma. 02632 April 23 2016 required for every p + page. CitylTown 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 Form:Subsurface Sewage Disposal System-Page 3 of 17 a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Heather Lane Property Address Monica Kicklighter Owner Owner's Name information is Centerville, Ma. Ma. 02632 A nl 23 2016 required for every p page. Cityrrown 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%day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Heather Lane Property Address Monica Kicklighter Owner Owner's Name information is required for every Centerville, Ma. Ma. 02632 April 23,2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.) ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form lu Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 Heather Lane Property Address Monica Kicklighter Owner Owner's Name information is required for every Centerville Ma. Ma. 02632 April 23,2016 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® 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 gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Heather Lane Property Address Monica Vicklighter Owner Owner's Name information is Centerville, Ma. Ma. 02632 April 23 2016 required for every P page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 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: Sump pump? ❑ Yes ® No Last date of occupancy: currentDate 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Heather Lane Property Address Monica Kicklighter Owner Owner's Name information is Centerville, Ma. Ma. 02632 April 23,2016 required for every P page. Citylrown 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: No records 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) (f yes, attach previous inspection records, if any) ❑ Innovative/Altemative 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 Forth: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 Heather Lane Property Address Monica Kicklighter Owner Owner's Name information is required for every Centerville, Ma. Ma. 02632 April 23 2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (f known)and source of information: 19 years. As-Built plan dated 8/27/97. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3.5' feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: +25'feet Comments(on condition of joints,venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 2.5' 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: 81 x 5.2'W x 5.3'H Sludge depth: 1" t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Heather Lane Property Address Monica Kicklighter Owner Owner's Name information is required for every Centerville, Ma. Ma. 02632 April 23,2016 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle 23" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 24" How were dimensions determined? measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The septic tank does not need to be pumped out at this time. No evidence of leakage. Inlet tee is PVC. The outlet is a concrete baffle. 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-3113 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 Heather Lane Property Address Monica Kicklighter Owner Owner's Name information is Centerville, Ma. Ma. 02632 April 23 2016 required for every P , page. City/Town state Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 Heather Lane Property Address Monica Kicklighter Owner Owner's Name information is required for every Centerville, Ma. Ma. 02632 April 23, 2016 page. Citylrown 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.): D-Box is in good condition. Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) pocate on site plan, excavation not required): If SAS not located, explain why: The septic tank and D-Box are functioning correctly.Therefore,the SAS is draining properly. t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form i; Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Heather Lane Property Address Monica Kicklighter Owner Owner's Name information is required for every Centerville, Ma. Ma. 02632 April 23,2016 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 3 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/aftemative system Type/name of technology- Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): No evidence of hydraulic failure. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3113 This 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 13 of 17 c • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments a 46 Heather Lane Property Address Monica Kicklighter Owner Owner's Name information is required for every Centerville, Ma. Ma. 02632 April 23,2016 page. Cityfrown State Zip Code Date of Inspection D. System Information (cunt.) 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 Forth:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Heather Lane Property Address Monica Ktcklighter Owner Owner's Name Is required ffor every Centerville,Ma. Me. 02632 April 23,2016 page. cityrrown State Zip Code Date of Inspection D. System information (cost.) Sketch Of Sewage;Disposal System: Provide a view of the sewage disposal system,including ties to at least two perm9nent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.Check one of the boxes glow: ® hand-sketch in the area below ❑ drawing attached separately ,* e F !Sins•3113 Title 5 Offer Inspection Form:Suhsurface Sewage Dsposel System•page 15 of 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 Heather Lane Property Address Monica Kicklighter Owner Owner's Name information is Centerville, Ma. Ma. 02632 Aril 23,2016 required for every p page. City/Town 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: 20' 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: From the previous Title 5 report on file. ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Determined from the previous Title 5 report on file. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins-3113 Title 5 Official Inspection Forth: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 46 Heather Lane Property Address Monica Kicklighter Owner Owner's Name information is Centerville, Ma. Ma. 02632 April 23 2016 required for every p + page. Cityrrown 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 Form:Subsurface Sewage Disposal System•Page 17 of 17 � i -�� b F1ea1�Ir,e,r 10, . � �� ,i I1� , 00 -2, $ 50.00 No. 27- Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ZippYication for Moozal *pgtem Construction 3dermit Application for a Permit to Construct( )Repair iXX)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 46 Heather Lane Owner's Name,Address and Tel.No. David Litchmen Centerville,Mass. 02632 46 Heather Lane Centerville,Mass Assessor's Map/Parcel 02632 Installer's Name,Address,and Tel.No. 508-775-3338 Designer's Name,Address and Tel.No.508-775-3338 J.P.Macomber & Son Inc. J.P.Macomber & Son Inc. Box 66 Centerville,Mass. 02632 Box 66 Centerville,Mass. 02632 Type of Building: Dwelling Flo.of Bedrooms # Lot Size sq.ft. Garbage Grinder( ) Other Type of Building RES No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 330 gallons per day. Calculated daily flow 3x110 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Existing 1000 Type of S.A.S.Existing 1000 pit. Description of Soil Clay based sand for 5' clean 5' to 8' Nature of Repairs or Alterations(Answer when applicable) AdIdi ng {-wo��_,�,1 nn rhamhar-, to f-hp Pxi_t-i ncr _-, tti r cvrctPm 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*issubyhis B ar f He lth.Signed Date 8f27197 Application Approved by Date $ 'r 9 Application Disapproved foing asons Permit No.__?7— V 6 c Date Issued ` $ 50.00 - No. / / Ylo� _ *. t f Fee _ 17� THE COMMON ALTH OF MASSACHUSETTS Entered n•computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 0(pprication for Mizpozal *r6tem Construction Permit Application for a Permit to Construct( )Repair(XX)Upgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No. 46 Heather Lane Owner's Name,Address and Tel.No. David Litchmen Centerville,Mass. 02632 46 Heather Lane Centerville,Mass Assessor's Map/Parcel '. 02632 3338 Installer's Name,Address,and Tel.No. 508-775-3338 Desi ner's Name Address and Tel.No. — J.P.Macomber & Son Inc. J.�.Macomber & Son Inc. Box 66 Centerville,Mass. 02632 Box 66 Centerville,Mass. 02632 Type of Building: Dwelling XX)No.of Bedrooms # # Lot Size sq. ft. Garbage Grinder( ) Other Type of Building — No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 330 gallons per day. Calculated daily flow 3x110 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Existing 1000 Type of S.A.S.Existing 1000 pit. Description of Soil Clay based sand for 5' clean 5' to 8' Nature of Repairs or Alterations(Answer when applicable) Adding two S96-ea4.l.on chambers to the existing septic system 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 issf td by thi B azcl cf H alth Signed ��� Date 8/27/97 Application Approved by Date 9 7 Application Disapproved for the Mowing reasons ' = n Permit No. 7- 6 6 0 Date-Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS, BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed ( )Repaired(XX)X Upgraded( ) Abandoned( )by J-P.Mac omber & Son Inc. at 46 Heather Lane Centerville,Mass. has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer J.P.Macomber & Son Inc. Designer J.P. r nc. The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date q- ,. 'n Inspector U 01- "') 50.00 No. /. /� �r --------------------------Fee (/ V THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS lwizpozal *pgtem Construction Permit Permission is hereby granted-to Construct( )Repair))Upgrade( )Abandon( ) System located at $1T 46 Heather Lane Cente ille,Mass. and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date: U �-7 - / 7 Approved by r - t CERTIrICKFION Or sia— 'Ell .AND Al'1'LICA'1'ION FOR A DISK I . WORKS CONSTRUCTION pLltnll'I' (NVI'1'110U'1' DESIGNED PLANS) 1, _Joseph P Macnmhar .T�.�_.... . ccrtily tli:jt the application for disposal works construction permit signed by me d-.-Led _ 8/27/97 , concerning the priperty located at 46 Heather Lane Centerville,Mass meets all of the following criteria: • There are no wellands within 300 fc.t of the proposed septic system • There arc no private well$ within 15o feet of the proposed septic system • The observed grouwidwatcr table .s l•Lct or l;reatcr below the bottom of the leaching facility There is no increase in flow ond/oi change in use proposed • There are no variances requested or uccdcd. SIGNED : DATE: 8/27/97 LICENS EPTIC SYS'FE4:\v.,1 ! STALLCIt IN THE HE TOWN OF BARNSTABLE NUMBER (Attach a sketch plan of the proposed s;;;cm. Also if We licensed installer posesses a certified plot plan, this plan should be sub:uiucdj. ��t ,� 1 0 III ' 4 Z, 2Q,.3 4 918 756 us Postal Service Receipt for Certified Mail No Insurance Coverage Provided. Do not use for International Mail See reverse Sent to / 1 / Street&Nu m e ,— X a—.f;J� Post Office,State,&ZIP Cade Ize-x, Postage $ Certified Fee Special Delivery Fee Restricted Delivery Fee LO Return Receipt Showing to Whom&Date Delivered a Return Receipt Showing to Whom, Q Date,&Addressee's Address 0 TOTAL Postage&Fees $ C") Postmark or Date 0 LL a Stick postage stamps to article to cover First-Class postage,certified mail fee,and charges for any selected optional services(See front). 1. If you want this receipt postmarked,stick the gummed stub to the right of the return address leaving the receipt attached, and present the article at a post office service window or hand it to your rural carrier(no extra charge). 2. If you do not want this receipt postmarked,stick the gummed stub to the right of the a) PC return address of the article,date,detach,and retain the receipt,and mail the article. LO 3. If you want a return receipt,write the certified mail number and your name and address rn on a return receipt card,Form 3811,and attach it to the front of the article by means of the gummed ends if space permits. Otherwise,affix to back of article. Endorse front of article a RETURN RECEIPT REQUESTED adjacent to the number. a 4. If you want delivery restricted to the addressee, or to an authorized agent of the C addressee,endorse RESTRICTED DELIVERY on the front of the article. M 5. Enter fees for the services requested in the appropriate spaces on the front of this E receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811. li 6. Save this receipt and present it if you make an inquiry. 102595-97-B-0145 n. w a SENDER:. I also wish to receive the V ■Complete items f and/or,2 for additional services. i ■Compete itsA 3,4a,and 4b. following services(for an 0 ■Print your name and address on the reverse of this form so that we can return this extra fee): 2 card to you. ■permit.this form to the front of the mailpiece,or on the bads if space does not 1. ❑ Addressee's Address ■Write'Retum Receipt R uested'on the mail piece below the article number. ry ■The Return Receipt willow to whom the article was delivered and the date 2. ❑ Restricted Delivery to c delivered. Consult postmaster for fee. a 3.Article Addressed to: 4a.Article Number /y p r�i d I d ,p Z/17�pvlt- E 7,> 6 c /vim CL�l(i(� h7� 4b.Service Type ZC ❑ Registered Certified Cn ❑ Express Mail ❑ Insured e jLew/ l e J IM# QZi�32— ❑ Retum Receipt for Merchandise ❑ COD c c 7.Date f Delivery Z-2.3� " p 5.Received By:(P' t Nam ) 8.Addressee's Addre s(Only if requested w and fee is,paid) . : r 6.Signature. Addre e'orAgent) ~ o b2595-97-B-0179 Domestic Return Receipt , UNITED First{"lass Mail STATES POSTAL SERVICE Poslig &F,pes Paid ` USPS Permit No.G-10 • Print your name, address, and ZIP Code in this box• Public Heal{b Divisla" Town of Bainstabte P Box 534 02601 r "yannis,MassachuseM rT; i I30, 00� Town of Barnstable .� Department of Health, Safety, and Environmental Services eA""AK Public Health Division 4� � ter " 367 Main Street, Hyannis MA 02601 t oe: 508-790 6263 Thomas A.McKean,RS,CHO FAX:- 508-790.6304 Director of Public Health ire DATE: 2� l c,3-7 )) o _ ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE,TITLE 5. The septic system owned by you located at q& was inspected r on by a Massachusetts licensed septic inspector. —�`11-'I P P 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: o-r '► e m rz��,� o A �vk over 1� �. op You are directed to hire a licensed ToM 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 OF THE BOARD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health ,v,enn�m.ruu�te� s 0 i COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS _ DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE HINTER STREET. BOSTON, MA 02108 617.292.5500 WILLIASt F \ELD TRL DY CO\T Governor Sr,rc tan ARGEO PAUL CELLUCCI DAVID B STRURS Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION Property Address: 46 Heather Line Centerville,Mass. Address of Owner: Date of Inspection:8/20/97 (If different) Name of Inspector: Joseph P. Macomber Jr . I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: Joseph P. Macomber & Son, Tnc . Mailing Address: OX b Centerville M 2-0066 Telephone Number: 508-775-3338 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 reeds Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit 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 authoriry. 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 as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: BI SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection, or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/2S/97) Page 1 of 10 DEP on the World Wide Web: httpwwww.magnet.state.ma.us/dep Printed on Recycied Paper all SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 46 Heather Lane Centerville Ma Owner: David Litchman Date of Inspection: g/2 0/9 7 B) SYSTEM CONDITIONALLY PASSES (continued) gLD Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced Alb 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: Al 0 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: VP 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 PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: A)8 The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone 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 1,119 _(approximation not valid). 3) OTHER i� II (revised 04/25/97) P&q• 2 of 10 f J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 46 Heather Lane Centerville Ma Owner: David Litchman Date of Inspection: 8/2 0/9 7 D) SYSTEM FAILS: You m st indicate ei;• er "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CN1R 15,303. The bans for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes NO Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Z _ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ Liquid depth in & A 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 _g. a'r4lUL!!`y t 1 l��qusr �1 fi 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: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No �WW the system is within 400 feet of a surface drinking water supply AX 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 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 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 46 Heather Lane Centerville Ma Owner: David Litchman Date of Inspection: 8/2 0/9 7 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner,�occupant, or Board of Health. None of the system components have been pumped for at least two weeks and'the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or - � as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non sanitary or industrial waste flow. 4 _ The site was inspected for signs of breakout. _ All system components, 'e*luding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. — The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if djfferent from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)) (revised 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 46 Heather Lane Centerville Ma Owner: David Litchman Date of Inspection: g/2 0/9 7 FLOW CONDITIONS RESIDENTIAL:11 Design flow. '`J V R.p.d./bedroom for S.A.S. Number of bedrooms: Number of current residents: Garbage grinder (yes or no)- Laundry connected to system (yes or no):k Seasonal use (yes or no):& Water meter readings, if available (last two (2) year usage (gpd): Iq 6- A/P /�- Sump Pump (yes or no):NO l �j 0 1,67W ( Last date of occupancy. 7r COMM ERCIAUINDUSTRIAL: �^I Type of establishment: Design flow:-A)-22-galIons./day Grease trap present: (yes or no)&L/f industrial Waste Holding Tank present: (yes or no)�A Non-sanitary waste discharged to the Title S system: (yes or no)44 water meter readings, if available: d),4 V'9 Last date of occupancy: AA OTHER: (Describe) AIR Las( date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source ol information 941 T n System pumped a pan of inspeaion: (yes or no)-)PIS 7 If yes, volume pumpe �--v�y--6�D�.$,al�lons/� Reason for pumping: l�,lv(f�d—/d C � -Y TYPE OF STEM Septic tank/distribution box/soil absorption system L)Q Single cesspool AAP Overflow cesspool _A)D Privy ,(�fZ Shared system (yes or no) (if yes, attach previous inspection records, if any) 4_ I/A Technology etc. Copy of up to date contract? Other AP OXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) (r•vi.•d 04/25/97) ➢.9. 5 of 10 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 46 Heather Lane Centerville Ma Owner: David Litchman Date of Inspection: 8/2 0/9 7 BUILDING SEWER: (Locate on site plan) Lie" Depth below grade: ru% Material of construction; _ cast iron j/40 PVC — other (explain) Distance fro Vivate water supply well or suction line Diameter Comments: lcondit on of joints, venting, evidence of le kage, r ' SEPTIC TANK: 14� eV,4A�4CJJ (locate on site plan) ny/ Depth below grade:c� Material of construction: Zncrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age&?d Is age confirmed by Certificate of Complianceo(Zd (Yes/No) Dimensions: / O AJG' � &4yt-�* "- Sludge depth:^zk/4CyL- Distance from tom sludge to bottom of outlet tee or baffle:T61Ce, Scum thickness:Z�- Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bosom of outlet tee or affle:� How dimensions were determined: Comments: (recommendation for pumping, conditiqn of inlet and outlet tees or baffles, depth of li uid level in relation to outlet invert, structural inte riry, vidence of leaks e, etc.) & M w J.,v I GREASE TRAP:.44�W, (locate on site plan) Depth below grade:�/4 Material of construct ion4{&concreteNiOmetalAIAiberglass4UAPolyethyleneR/Aother(explain) Nl4 Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle:&d- Distance from bottom of scum to bottom of outlet tee or baffler& Date of last pumping: Al�y Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 46 Heather Lane Centerville Ma Owner: David Litchman Date of Inspection: 8/2 0/9 7 TIGHT OR HOLDING TANK:Ad&kVTank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: Material of con s(ructionA—'r.*oncrete4AmetalNAFiberglass.V}PolyethyleneA/�other(explain) Dimensions: AIA Capacity: N14 gallons Design flow:_gallons/day Alarm level: /194 Alarm in working order Yes;//A No Date of previous pumping: '44 Comments. (condition of inlet tee, condition of alarm and float switches, etc.) is .67- .,��►- DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: Comments: (not if le I and di s ribution is equal, evidence of solid ryover, evidence of leakage into or out of box, et .) Z'` O PUMP CHAMBER:Ahi1116- (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order (Yes or No)_?,6' Comments: (note condition of pump chamber, condition of pumps and appunenances, etc.) � �- �- (rwlaod 04/25/97) P•go 7 of 10 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 46 Heather Lane Centerville Ma Owner: David Litchman Date of Inspection: 8/2 0/9 7 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: 0 leaching galleries, number: leaching trenches, number,length: leaching fields, number, dime ions: overflow cesspool, number Alternative system: AL�14 Name of Technology: d �l Comments: (no condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) r eAvg eof r ' CESSPOOLS: jZiX)C, (locate on site plan) Number and configuration: Aj)q J Depth-top of liquid to inlet invert: AA Depth of solids layer: A)A Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: AM infRll (cesspoo must be pumped as part of inspection) (�g22oV S r� •r br /r Ji��e yr' 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: (nom condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (rwimed 04/15/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Properly Address: 46 Heather Lane Centerville Ma owner: David Litchman Date of Inspection: 8/20/97 SKETCH OF SEWAGE DISPOSAL SYSTEM: ,nclude ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) r (r.yi..d 04/25/97) Pag• 9 of 10 J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 46 Heather Lane Centerville Ma Owner: David Litchman Date of Inspection: 8/2 0/9 7 Depth to Groundwater jL Feet 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.) _ZDetermine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use l'SCS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) Map Cape Cod Water Table Contours and Public Water Supply & Wellhead protection Areas. September 1995 Water Resource Office Cape Cod CommisSION (rovisad 04/25/97) Pay• 10 of 10 (- ..-..-. .. .rTr-..-r'-..r.n.n rvr�.r.nn.m..:-.�.-.+.•..:+..r-n+r..+m-nay nr�+s n-'+ ��r-n-.-.-T-,r---- - - TOWN OF Barnstable WARU OF HEALTH SUIfSURFACF 9EHA(;E I)ISPUSAL SYSTEM I NSI'FCTION FORM - PART U CFWF1 FI CAT 10',' �_ f.. __ r ... .-- i..---r...-.�n.,-..r1.r.-rn+n.-r-r.-�•.�•-.,m.-�...n.r--rww+�.+v�rrr�.�..s-...-nr. m..n-....r,-,-..-,-.-.-.-.r.-r _�,-- ,-'- - -TYPE OR PRINT CI.EARL1'- PROPERTY INSPECTED STREET ADDRESS 46 Heather Lane Centerville,Mass. ASSESSORS MAP , ©LOCK AND PARCEL # O w N E R ' s NAME David Litchmnan PA177' D - CE!?TIFICATION I NAME OF INSPECTOR Joseph P. Macomber Jr . COMPANY NAME Joseph P. Macomber & ''� n , Inc . COMPANY ADDRESS Box 66 Centerville , Ma . 02632-0066 S t r e v t Town or City St►t. ;,P COMPANY TELEPHONE (508 775 -3338 FAX ( 508 ) 790 -1578 CERTIFICATION STATEMENT V I certify that I have personally inspected the sewage dieposa-I system n _ this nddress and that the information reported is true , accurate , and complete as of the time of .inspection , The inspection was performed and an,,, recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintennnce o , on- site sewage disposal systems . Check one : System PASSED The inspection ;lhich I have conducted has not found any information which indicates that the system fails to adequately protect public healLh or Lhe environment as defined in 310 CMR 15 . 303 . Any fail ( -e criteria not evaluated are as stated in the FAILURE CRITERIA section o .` is form . System FAILEU:' \ The inspection which I have conducted has found that the system f '_ j,, . 1s _o Protect the 'public health and the environment in accordance with Tite 5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . inspector Signature l Date one copy of tf� is ert.ification must be provided to the OWNER , the DUYER ( -here appl icabl e ) and the DOARD OF HEAL7'II . • IC the inspection FAILED , the owner or operator shall upgrade the eyote ^ � ir.hin one year oC the date of the inspection , unless allowed or requi7ec: otherwise as provided in 310 CNR 15 . 305 , Par td c_ U �7 7 P ti _ Ssbyv 3��1'1 THE COMMONWEALTH OF MA.SSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the General Laws- Issued by The Department of Environmental Protection. u� s. ►v9s Acting Dircctor of tIlc W* ton of Watcr Pollution Control TOWN OF BARNSTABLE p L, Ale SEWAGE# T 7— y LOCATION VII,LAGE ASSESSOR'S MAP & LOT I� = 66 INSTALLER'S NAME&PHONE NO. A 7,0 d e e sew SEPTIC TANK CAPACITY r @ p O 5 LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUER OR OWNER ILD PERMIT DATE: '�? - / 7 COMPLIANCE DATE: 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 s.1te: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 ------ -.--- --- Id Ve tom-_ PH.GN E7 CALL OR J y3 TIME J1A M. F �U P.M. M OF PHONED FAX R, kJRNED PHONED If 3 �' UR CALL -. - AREA-C _ UMBER N ESSA "` PLEASE CALL �y WILL CALL AGAIN J40O3 EWALIA SESIGNED ._.... _ FORM _J .. € If aYJ NOTESx 4 i } F , Town of Barnstable Department of Health, Safety, and Environmental Services Public Health Division BAM to 9. �� 367 Main Street, Hyannis MA 02601 Office: 508-790-6265 Thomas A. McKean, RS, CHO FAX: 508-790-6304 Director of Public Health David Litchmen December 2, 1997 46 Heather Lane, 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 46 Heather Lane, Centerville was inspected on August 21, 1997, by Joseph Macomber, Jr., 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: Backup of sewage into system component due to an overloaded or clogged soil absorption system. • Liquid depth in leaching pit was less then 6" below invert 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. i 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. ER HE BOARD OF HEALTH T omas A. McKean, R.S., C.H.O. Agent of the Board of Health A