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HomeMy WebLinkAbout0001 HUCKINS NECK ROAD - Health 1 HUCKINS NECK ROAD, CENTERVILLE A= llll UPC 12534 No.2�153L0R '�T� HASTINGS,MN 1 a t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments lug 1 Huckins Neck Rd. Centerville, MA 02632 + � Property Address iNJ Albert Vezza 292 Winter St. Owner Owners Name Information is required for every Weston MA 02193 10/6/20IT!, page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, (07 use only the tab 1. Inspector: key to move your cursor-do not Paul Martin use the return Name of Inspector key. Cape Cod Septic Services 1� Company Name 350 Main St Company Address W.Yarmouth MA 02673 City/Town State Zip Code 508-775-2825 S15016 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 16.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 10/10/2017 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. { t (Sins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 �v !/S Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 1 Huckins Neck Rd. Centerville, MA 02632 Property Address Albert Vezza 292 Winter St. Owner Owner's Name information is required for every Weston MA 02193 10/6/2017 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: System in working condition. 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): (Sins•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 1 Huckins Neck Rd. Centerville, MA 02632 Property Address Albert Vezza 292 Winter St. Owner Owner's Name information is required for every Weston MA 02193 10/6/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N FIND (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 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1 Huckins Neck Rd. Centerville, MA 02632 Property Address Albert Vezza 292 Winter St. Owner Owner's Name information is required for every Weston MA 02193 10/6/2017 page. Cityfrown 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 '/z day flow t&ns•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1 Huckins Neck Rd. Centerville, MA 02632 M Property Address Albert Vezza 292 Winter St. Owner Owner's Name information is Weston MA 02193 10/6/2017 required for every page. Cityrrown 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.] El ® 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 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1 Huckins Neck Rd. Centerville, MA 02632 Property Address Albert Vezza 292 Winter St. Owner Owner's Name information is required for every Weston MA 02193 10/6/2017 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): 110x3= 330gpd 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 1 Huckins Neck Rd. Centerville, MA 02632 Property Address Albert Vezza 292 Winter St. Owner Owner's Name information is Weston MA 02193 10/6/2017 required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 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 2016=0gpd Water meter readings, if available (last 2 years usage (gpd)): 2017-3gpd Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Unknown 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 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1 Huckins Neck Rd. Centerville, MA 02632 Property Address Albert Vezza 292 Winter St. Owner Owner's Name information is required for every Weston MA 02193 10/6/2017 page. Cityrrown 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) (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): l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 1 Huckins Neck Rd. Centerville, MA 02632 Property Address Albert Vezza 292 Winter St. Owner Owner's Name information is required for every Weston MA 02193 10/6/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2006 Per BOH records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 40 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: +10'feet Comments (on condition of joints, venting, evidence of leakage, etc.): Line checked with camera and was found to be clean, properly pitched with no sign of root intrusion. Septic Tank(locate on site plan): Depth below grade: 30"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: 1500Gal Sludge depth: 3-4 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 1 Huckins Neck Rd. Centerville, MA 02632 Property Address Albert Vezza 292 Winter St. Owner Owner's Name information is required for every Weston MA 02193 10/6/2017 page. Cityrrown 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 Oil 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? Estimated Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1500Gal tank in good condition. PVC tees in place and clean. Tank at normal operating level. Inlet cover 8" below grade with outlet 30" below grade. 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 ,M 1 Huckins Neck Rd. Centerville, MA 02632 Property Address Albert Vezza 292 Winter St. Owner Owner's Name information is required for every Weston MA 02193 10/6/2017 page. Citylrown 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.): k n m e pumped at time of inspection) locate on site plan): Tight or Holding Tan (tank must b p p p ) ( p ) 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 ,M 1 Huckins Neck Rd. Centerville, MA 02632 Property Address Albert Vezza 292 Winter St. Owner Owner's Name information is required for every Weston MA 02193 10/6/2017 page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): H-10 DB-3 with 1 line in and 1 line out in good condition. Box is clean and level with minimal solids carryover. No sign of overloading or hydraulic failure. Cover 17" below grade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M °y 1 Huckins Neck Rd. Centerville, MA 02632 Property Address Albert Vezza 292 Winter St. Owner Owner's Name information is required for every Weston MA 02193 10/6/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2-500Gal ❑ 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.): 2-500Gal chambers with stone. 12.83x25'x2'. Chambers found dry at time of inspection with soil clean. No sign of overloading or 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•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 1 Huckins Neck Rd. Centerville, MA 02632 Property Address Albert Vezza 292 Winter St. Owner Owner's Name information is required for every Weston MA 02193 10/6/2017 page. Cityrrown 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.): l5ins-3/13 Title 5 official Inspection Form: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 1 Huckins Neck Rd. Centerville, MA 02632 Property Address Albert Vezza 292 Winter St. Owner Owner's Name information is required for every Weston MA 02193 10/6/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1 Huckins Neck Rd. Centerville, MA 02632 Property Address Albert Vezza 292 Winter St. Owner Owner's Name information is required for every Weston MA 02193 10/6/2017 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: +11, feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record 2006 If checked, date of design plan reviewed: Date 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: Test hole data per plan on file at BOH. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 1 Huckins Neck Rd. Centerville, MA 02632 Property Address Albert Vezza 292 Winter St. Owner Owner's Name information is required for every Weston MA 02193 10/6/2017 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 Form:Subsurface Sewage Disposal System-Page 17 of 17 Assessing As-Built Cards f Page 1 of 2 TOWN OF BARNSTABLE LOCATION•/ h(e 1 444 fib SEWAGE# -,a ss- VILLAGE C,"A,�J., • ASSESSOR'S MAP&PARCEL'.26,/ er6 y INSTALLERS NAME&PHONE NO. ��o�jl: Co•+�7�iur�o-+ h3q":��' L i SEPTIC TANK CAPACITY LEACHING FACILITY:(type).7- rN 41 CYr JW (size) V J1 0.73 X 1 NO.OF BEDROOMS .j OWNER / '(Ji PERMIT DATE: P-/O-o(v COMPLIANCE DATE: & Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY 14 i I • i�r '� � -2 http://www.townof bamstable.us/Assessing/HMdisplay.asp?mappar=251064&seq=1 10/4/2017 No6 THE COMMCDNWEAtLTH OF MASSACHUSETTS FEE .� -BOAR /�OF HJEA JLTH — OF APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct ( ) Repair ( ) Upgrade (Abandon ( ) - Complete System El Individual Components U S / / b Gam"=77-_-Z,A- L tali Owner's ame api ` Map Parcel# Gl W - _2)J—' �6 � 7 l i I��p;aller's N� /7/1, _��J `'� fiatDeig rr I-- � J� Ls'1 cVs y`�7 Y j QJ I `l D y�7�+.7/ Address ddress Telephone# Telephone# Type of Building: /i L Lot Size /S, Sq.feet Dwelling—No.of Bedrooms Garbage Grinder ( W Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min.required) 3 30 gpd Calculated design flow 3W 33 gpd Desi n flow provided. gpd Plan: Date �,)� Number of sheets _ Revision Date e11 I l a . Title 51 '0/an _'q /!✓64 AD Cre/r-,;&. W/1 Description of Soil(s) Y-� Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS 0?56 ige 5,404C ,71401 The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees of place a system in operation until a Certificate of Compliance has been issued b the Board of Health. g 7� Signed Date Inspections FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 /dam NO. -3 S',5 THE.COMMON.WE'AfLTH OF MASSQC:,HUiSETTS FEE BOARQ OF HEALTH CGJ� o F 4vv, � r APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct ( ) Repair ( ) Upgrade (�Bandon ( ) - 0 Complete System ❑Individual Components d-e Z Z lei' L cati n Owner's Name Map/Parcel# Address / `76 Iq 781- 13r- UG�2 Ly}t# c / Telephone# !/ 7' �[��`n staller's Name �/J 1 <e ti` '' qJ d`` Desig6er's`Namc / 7 S LyI.]dJTY-) P 1) M./I//,l!S 'r or/ /Ca-1 y,v— A) C)J7`„"w:/ 'Address 1aar esg SZ�)S �3�a7 Telephone# Telephone# `` r Type of Building: >7i J'/, L Lot Size 1Y,/,C) , Sq.feet Dwelling—No.of Bedrooms 3 Garbage Grinder Other—Type of Building No.of persons Showers" ( ), Cafeteria ( ) Other fixtures +' I Design Flow(min.required) 3 30 gpd Calculated design flow 3W,33 gpd Design`flow provided 3W' 3 gpd Plan: Date s- " �- " / �.J)�a Number of sheets 1 Revision Date �yt i ))"�O(e Title i�z � , � �t ,ti 9 XJrc>'i /� ��b %✓�l�v vt'l/g Description of Soil(s) 5,r-r P/G''1 _ Soil Evaluator Form No ., Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS 04 ,h7r�.t►'► The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees "of to place a system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date± �4 Inspections FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 NO.�� e - .� THE COMMONWEALTH OF MASSACHUSETTS FEE I Vc ,� 7rV3 If BOARD OF HEALTH CERTIFICATE OF COMPLIANCE Description of Worl c_ ❑ Individual Component(s) r� omplete System The undersigned here)by,certify that/the Sewage Disposal System;Constructed( ),Repaired( <Pgraded,(',),Abandoned( ) by: ! �7r l�J �, (_cJ�✓)7" ttG i ro 0 at has been installed in accordance with the provisions of 310 )5.00 (Title 5) and the approved design plans/as-built plans relating toa placation NQ-X-D(- 355 dated lz �TR 0 �O Approved Design Flow (gpd) Installer Designer: IT0 \ Inspector r:_:� l — Date The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 _._— ------------------•-----_--.—,_----_—_____...._______,.-,_ ___ ..,,.,_,.__-__,_-� N 5-5 THE COMMONWEALTH OF MASSACHUSETTS ' ��_ FEE iF.vy �5 Ia- BOARD OF HEALTH -�- DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to Construct S ) Repair ( ) Upgrade ( Abandon ( ) an individual sewage disposal system at / A, rn /` ,-r AC .s as described in the application for Disposal System Construction Permit No. D 3 5.��dated Provided: Conssttrruct'on shall be completed within three years of the da e of thi�''�i`tl All`ocal conditions must be met. Date C� �� o Board of ealth FORM 2 - DSCP DEP APPROVED FORM 5/96 F FORM 1255 (REV 5/96) H&W H088s&WARRENrM PUBLISHER'S; - BOSTON Stetson Hall 5094286367 p.2 Town of Barnstable • �°p' '` !• Regulatory Services . Thomas F.GeJer,Director eArwWAR= = Public Health Division Thomas McKean,Director 200 Mais$trcet,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer&Designer Certification Form Date: Designcr: ��r -},, Installer: Address: j�Q 34w,p RoA-D ,Address: 4/5 .Lo.4))4p 6kzzxl�- w on 0/U V& .11ir/o/o/`J'�i" 6a3)" was issued a permit to install a (date) (installer) septic system at F based on a design drawn by (address dated L,�I certify that the septic system referenced above was installed substantially according to the design, Which may include minor approved changes such as Iateral relocation of the . distribution box and/or septic tank. g I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component Of the septic system)but in accordance with State& Local Regulations. Plan revision or certified ilt by designer to follow. _JA OF tt�ter�� eye, tiller's Signature) A. No.s2'i 44 Nl� d Sa EVA0_'1- "5ueesagnature) (Affix DesiOWTSfamp Here) PLEASE RETURN TO BAWNSTABLE PUULIC ITPALTH DMSION. CERTIFICATE OF COMPLIANCE WFLL NOT BE ISSUED UNTIL BOT.1 THIS FORM AND AS- BUILT CARD ARE RI+;CEI<VFD BY THE MRNSTABLE PUBLIC HEALTH DIVISION. THANK YOXf. - Q:YX&-4dVSepti*Vesiper Cei-fficapon Form 1 J TOWN OF BARNSTABLE ° LOCATION kke4',,s Mt6.,c.A SEWAGE# ZXC--35r VILI•AGE ASSESSOR'S MAP&PARCEL _ (� INSTALLERS NAME&PHONE NO.&A-ko-W Qc 4,. �m, 5b8 711 SEPTIC TANK CAPACITY 15rafia.` r LEACHING FACILITY:(type)2 &kio ak (size) ?ff,4 M4.5 (Z° NO,OF BEDROOMS 5 OWNER AAA. s r Ve7ZC� PERMIT DATE: 2Llo''6e_ COMPLIANCE DATE: (p Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility)• Feet Edge of Wetland and LeachingFacility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY J e. $vim Q WA Q3 Az-;51r TOWN OF BARNSTABLE LOCATION /�uc•C,hJrc�i V;!7 SEWAGE# VILLAGE ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. -3z4'"`lag'�G SEPTIC TANK CAPACITY /f 6�L LEACHING FACILITY: (type),?- r'oo GpG - (size) /,2,T)X"X NO. OF BEDROOMS .3 OWNER 006.-/ (J<z PERMIT DATE: Q�'/G-o C� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist-. on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY Syko„i �3� -7i r Urn TOWN OF BARNSTABLE �+ LOCAT[ON 4VL�mrlGl�� AR4L.ED AffwONav�' VILLAGE_� fyt1� ASSESSOR'S MAP & LOTas/ �L7 INSTALLER'S NAME&PHONE NO. L.(1T 7(6 SEPTIC TANK CAPACITY a�A � A� LEACHING FACILITY: (type) (size) NO.OF BEDROOMS A /7 BUILDER OR OW NER !/GZZ PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachi g facility) �— Feet Furnished by `��1 SaCCiO✓► J , t�D/� A (3Ac,k B� � Q i a 1 3;& 49(o � Sa 3y TOWN OF BARNSTABLE LcIC-47110N k\w 9— _ SEWAGE # VILLAGE ez&ka ASSESSOR'S MAP & LOT-,��06 1 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) j NO.OF BEDROOMS BUILDE Oft OWNER 1 MtM f DATE: '� �� 1��I COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet by L r - - >z- $3 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED FAILED INSPECTION JUN 2 9 2004 TITLE 5 TOW HEArLTH DIEPT. OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTET$KPRM,�c5—( PART A PARCEL ; O CERTIFICATION LOT v._ a Property Address: 1 Huckins Neck Road Centerville, MA 02632 ' Owner's Name: Joseph Mariano an � a Owner's Address: 292 Winter Street c Weston, MA 02493 Date of Inspection: June 13, 2004 r j ' cn U7 cu Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O. Box 49 F Osterville,MA 02655-0049 r— Telephone Number: (508)862-9400 d rm CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Ysubmia Fa' Inspector's Signature: Date: June 18, 2004 The system inspector shay of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1 Kuckins Neck Road Centerville, MA Owner: Joseph Mariano Date of Inspection: June 13, 2004 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes, no or not determined(Y,N,ND) in the for the following statements. If"not determined", please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 f Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1 Huckins Neck Road Centerville, MA Owner: Joseph Mariano Date of Inspection: June 13, 2004 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: I Huckins Neck Road Centerville, MA Owner: Joseph Mariano Date of Inspection: June 13, 2004 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped . ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. _ ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this forma Yes (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. NOTE:Single cesspools automatically fail in the Town of Barnstable. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or.failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. r 4 Page 5 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1 Huckins Neck Road Centerville, MA Owner: Joseph Mariano Date of Inspection: June 13, 2004 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection ? ✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS, located on site? ✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ _ Existing information. For example,a plan at the Board of Health. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 Page 6 of I I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1 Huckins Neck Road Centerville, MA Owner: Joseph Mariano Date of Inspection: June 13, 2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): n/a Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder(yes or no): n1a Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): _______gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Unavailable Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system 1(2) Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Unknown(original) Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1 Huckins Neck Road Centerville, MA Owner: Joseph Mariano Date of Inspection: June 13, 2004 BUILDING SEWER(locate on site plan) Depth below grade: None Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: Sludge depth: 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.): GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1 Huckins Neck Road Centerville, MA Owner: Joseph Mariano Date of Inspection: June 13, 2004 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and'float switches,etc.): DISTRIBUTION BOX: None (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 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: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 ' Page 9 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1 Huckins Neck Road Centerville, MA Owner: Joseph Mariano Date of Inspection: June 13, 2004 SOIL ABSORPTION SYSTEM(SAS): None (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): CESSPOOLS: ✓ (cesspool must be pumped as part of inspection)(locate on site plan) #1 #2 Number and configuration: 1 single cesspool I single cesspool Depth-top of liquid to inlet invert: 4' 4'6" Depth of solids layer: 10"sludge 6"sludge Depth of scum layer: -- -- Dimensions of cesspool: 5'W x 5'T x 8'bottom to grade 5'W x 5'T x 8'bottom to grade Materials of construction: Cesspool block Cesspool block Indication of groundwater inflow(yes or no): None None Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): Cesspool#1 was dry. The scum line was 3'up from the bottom. In cesspool#2 the scum line was up to the bottom of the pipe The cover was 15"below grade. Single cesspools automatically fail in the Town of Barnstable PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 9 • Page 10 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: I Huckins Neck Road Centerville, MA Owner: _ Joseph Mariano Date of Inspection: June 13, 2004 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. L3;6 9 � sa 3y 10 Page 1 I of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1 Huckins Neck Road Centerville. MA Owner: Joseph Mariano Date of Inspection: June 13, 2004 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 35 +/- feet Please indicate(check)all methods used to determine the.high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic maps and water contours maps the maps were showing approximately 35'+/ to ground water at this site. This report has been prepared and the system inspected and failed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,written or implied, relating to the system, the inspection and/or this report. 11 COMMONWEALTH OF MASSACHUSETTS 1p EXECUTIVE OFFICE OF ENVIRONMENTAL A.FF RECENC DEPARTMENT of ENVIRONMENTAL PROTEC 1997 ~ MAR 2 S ONE WINTER STREET, BOSTON MA 02108 (617)292-5500 TOWN OF BARNSTABLE HEALTH DEPT WILLIAM F.WELD TRUDY Governor t V lug ARGEO PAUL CELLUCCI RUHS Lt. Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A �� A CERTIFICATION e Property Address: �cJL(.(�'t�s �QC���/. � Lt"(�L okddress of Owner .cu,d, Date of Inspection: 0 y� (If different) Name of Inspector: ►y,,ya�� �_�_o Company Name, Address and Telephone Number: Fer �a _rnc_ I T"l..Sv,?«—t 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 Faits Inspector's Signature Lkt� r 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 authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria 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 completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, 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 11/03/95) 1 , i� Printed on Recycled Paper Nk.- -- • �;,' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) / Property dress: vG� I�c S 2GK CSZ�.�2cvs GL 2 a Owner: '` Date of Inspection: j j*]YSTEM'CONDITIONALLY PASSES (continued) _ Sewage backup or breakout or high static water level observed in the dist ution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The syst will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year d 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 EALTH: Conditions exist which require further evaluation by a 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 H TH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEA H AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 eet of a surface water Cesspool or privy is within 5 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE OARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONIN IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a eptic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water s ply. _ The system h a septic tank and soil absorption system and is within a Zone I of a public water supply well. _ The system as a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The syste has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply ell, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free fr m pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 pp 3) OTHER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued)) / Property Address: Owner: VC� .sl�'� �—f/P.0 ) /cod .✓t l!'e v� .S /'�cLf2.lr!c..Ka� , Date of Inspection: ��--- Dj SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined i 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determin what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clo ed SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters ue to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an ov rloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available vol a 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 surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I f a public well. Any portion of a cesspool or privy is within 50 fe of a private water supply well. Any portion of a cesspool or privy is less than 00 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the wel has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compou ds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large syste in addition to the criteria above: The system serves a facility/ina flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety anment because one or more of the following conditions exist: the system is with a surface drinking water supply the system is withf a tributary to a surface drinking water supply the system is to en sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a public water s ply well) The owner or operator of any uch system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5 0 and 6.00. Please consult the local regional office of the Department for further information. (revised 11/03/95) 3 n r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 11 v`li[ Owner: Date of.Inspection: Check if the following(have been done: Pumping information was requested of the owner, occupant, and 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. ILWAs built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for 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 or approximated by non-intrusive methods. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: ✓ITT ��t, kS �e�K GCf� Owner: Q, S /`ecae#a KG( Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: nO gallons Number of bedrooms: Number of current residents:ol— Garbage grinder (yes or no):_L�p Laundry connected to system (yes or no): Seasonal use (yes or no):_QD Water meter readings, if available:_ Iu%,Q a Last date of occupancy:�i�g�„�— COMMERCIAUINDUSTRIAL: Type of establishment: Design flow: gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: fz , '\d System pumped as part of inspection: (yes or no)_po If yes, volume pumped: gallons 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) Other (explain) '� S,-,I APPROXIMATE AGE of all components, date installed (if known) and source of information: 3C7 Sewage odors detected when arriving at the site: (yes or no) Nv (revised 11/03/95) 5 e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property A ress: W�vc-rrh5 /� �o� 6--Aal Owner: Pt. S Date of Inspection: O 3 SEPTIC TANK:_ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Sludge depth: 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: Comments: (recommendation for pumping, condition of inlet and outlet tees or baff/depth uid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) GREASE TRAP:_ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP /ther(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or b le: Distance from bottom of scum to bottom of outle tee or baffle: Comments: (recommendation for pumping, condition of' let and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ,/ SYSTEM INFORMATION (continued) Property Address: ✓/ #lxeuS ve_d Qx _ 6jetNC Owner: Date of Inspection: 7/ / TIGHT OR HOLDING TANK:_ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP—other(explain) Dimensions: Capacity: Qallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of s ids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER:_ (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump cham er, condition of pumps and appurtenances, etc.) (revised 1/3/95) 7 K fi SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C //'' SYSTEM INFORMATION (continued) ress:� Lxff 1 � � .4.S A -d- Owner: �ey K 5 Date of Inspection: o � �y/yam SOIL ABSORPTION SYSTE/M (SAS):__fi�o (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: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) CESSPOOLS: S (locate on site plan) Number and configuration: �gbt)ML Depth-top of liquid to inlet invert: -_. -" x 3 sr Depth of solids layer:�&' ;XS b" Depth of scum layer: b" 1A o" Dimensions of cesspool: Lx't(,—CA MZ LA Materials of construction: -. es Q_-A Indication of groundwater: tk� inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of po ing, condition of vegetation, etc.) PRIVY:b?.L) (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ( �!t> u.5 //� 11�'d - Owner:�� Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' a c� 0- 2 DEPTH TO GROUNDWATER Depth to groundwater:115 feet c method of determination or approximation: \7•S•�eo\o , Vu avc.� ,4� g' PP (revised 11/03/95) 9 k ' _ = P �f pig- 17 10-11", " •f� � -;% - g � :� 2 X/3T, -- t �oRT�co � fr ' +. + F 7/ $ A%a tie C& oL o ®�3 i ,��,e ,.� '� 4QS� oKe+Icell R mac, tAl ir.-F Fa ts.-p r. �• � scAu:: Avraoveo er: �. �i r DATE p flE915E0 evrs 09AWING NUMBEfl - j ,�`y� � \ L.F�_:�,J� � �-�,�s'%��G Car✓:��J'�s . — � �-� ©_cam r v�� �i� - .� Bg/ ._. - ,� �✓/�i iDn/S b3�3.��v ©�✓ /-�r,:�r��'I�� 1�9T�J�''1, jE,{5 � 28 ' -- j 74 4; ' ` ` Q ✓ -- 1 G� ✓ 7, 7a,C a c — ��.� � s 1 C�Ur✓.i,� -- 76 14) 1 n ' 9• DEEP OBSER VA TION HOI_ E LOG F 7 ) � %x%�i/�✓ . � ''�rpr�i � /off c�,� `�J • W(• �i�p . ; 1 .�'�" � ` =�G.�`a,cx3 � I I' ,,.�', —�/1"' C' ��•-��E•-��!,� �dY��s/c3' --- " 7 -- � �: .._._7,,.� .` 2 33 - _ '70 A,; 1 �rgO S Y _ Fya Ice, _ 9• 9 �� °� c� ---,a� --- ;� � � EL.-SQ,�aG�' ��!`!!a7`--(�..�ot/,�1.� 1�Y�1' 'r,.r9`-�✓ p / �0° ' �'• sfi 1 �. TOP OF FOUNDATION CONCRETE COVERS ' ( p^ ,� .� 4 CAST IRON 9r »%'rrrr>~ _, . .,• „, „, �r;-��} L = � OR SCHEDULE 404 SCHEDULE 40 P.V.C. (ONLY) ' ' LEACHING TRENCH (/)REQ.PIPE- :t (r P.V.C.PIPE MIN, —I 9 MIN _ I/8��- I/2�� WASHED STONE_PITCH 1/4 PER•FT 2 " PITCH II/4 PER.FT. -::�,�.. ..• .«.,, •r.e. ---.:+.L.i.:� .,n �:�_.u=r:r:.._L_ .r fi / ( / o'• INVERT � Ba E3 :C E±J'<LJ.�1 � ` Y_ i 4 E � ... E NV R C]j%�7 Cir�'�L]�'tn,;� �.�d� 24 A L9 TANK �I�2 T D)ST. ELN .-5� ;o % � b �- r f SEPTIC , ,• / j ___ . - ,.• INVERT ,, 7 BoX alCtyCl; :;C]it5; �`t;Clip' l GAL.. INVERT IN , . _ . • . �� ELt} -. /. INVERT � EL�.�i.�� �(Z) REQ. 3/4 -II/2 -f ' 6'CrRUSHED STONE I Chamber STONE H— All LIS — : 411 \�l' A. ,�cc// p PROFI LE OF077 1/ LANE :• ��`lQ IDS' " 7 GROUND WATER TABLE �C LANE SO[L LOG SEWAGE DISPOSAL SYSTEM TYPICAL •CROSS SECTION P f-�l NNEY".S N0 SCALE LEACHING TRENCH . DATE/4?►��•�Q�J/ TIME . //rQ� � _ NO SCALE- TEST POLE 1 TEST HOLE 2 , ELEV. .. . . .. . ... DESIGN DATA : y. 'III WA-SHED -36"MAX. SANE 71( 2 lc��r,/..CA✓t3 TOTAL ESTIMATED FLOW GALLONS/DAY _ ':�: _ of ; _ , 4 _BOT TOM LEACHING AREA ?eal� 7SO.FT./TRENCH Q ,����. . 1 1 1 L l V '9 �i . ,�? (�,•/,n �t rh/� SIDE .LEACHING _.AREA' . f �. .. .-17 SQ.FT./TrRi:NCH 24° HUCKIN S NEC K RD.� CENTERVILLE, /A � �� � � ; GARBAGE DISPOSAL . 'lY�. ..(50% AREA INCREASE) � 70 7 0 _ FOR �"1 f-F . TOTAL LEACHING AREA .� 2,. PERCOLATION RATE .< .!'?!!�.f -PEcR.INCH CIS LE ��L. �A r� r LEACHING ARE . PAR A N RAT'a- '/�r S _ t -A PER COL ,/ 0 ' l • / JL� t� G� /�� Gait .s �a �7�.�7 , �9 _„ ' �� `'� cRcuNo mare �,rc r APPROVED .. . . . . . . ! .. .. .. BOARD Or HEALTH Ta LE (. / .WATER ENCOUNTERED DATt _ pJ�N qS • •.. • . .• • • ••• � AGENT OR INSPECTOR • � OF } .. WITNESSED Y � �: S so p. 1-9 aeaRo or HEALTH . . 6T � . . . cn � ' '` Cam✓ Lx,. ' roa PETITIONER