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HomeMy WebLinkAbout0044 JOHNSON LANE - Health A A .Johns—on Lane Centerville A = 193 043 Omrford, NO. 1521/3 ORA 100/0 � 1 � -kr, d- � BL .. No. 1;:� \ Fee BOARD OF HEALTH TOWN OF BARNSTABLE 01ppYtcattou jfor Yell Con0tructtou permit Application is hereby made for a permit to Construct V01' Alter( ), or Repair( ) an individual well at: Location-Address Assessors Map and Parcel Owner r Address �� Q�� �,�)�' (07 �l. 1(il�l -FCC 'ZOV-, S SO. oe(R��S Installer-Driller n Address �J G o,3 Type of Building / Dwelling Other-Type of Building No. of Persons Type of Well t� � �i�2(1 Capacity sp�, Purpose of Well 4C�V, 1 Vf21� Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Certificate jogmplia een issued by the Board of Health. Signed 2 Date Application Approved By /�"/�� Date Application Disapproved for the following reasons: Date Permit No. r�— L4 Issued z/—a Date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Compliance THIS IS TO CERTIFY,that the individual well Constructed( ), Altered( ), or Repaired by V,�to `� Installer at �J" C . has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well rotection Regulation as described in the application for Well Construction Permit No.4:) '�O I L4 "C'")-IDated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector No. W t G Fee BOARD OF HEALTH TOWN OF BARNSTABLE Zlpprication _for Vern Cou5tructiou Permit Application is hereby made for a permit to Construct Alter( ), or Repair O an individual well at: �Gy_ d YYl�1 Iq3 PLl� c��l3 Location-Address Assessors Map and Parcel Owner �� Address �/ ' I J��L ) S l 07 �L. �J�—► l �� .So. Installer-Driller Address Type of Building Dwelling Other-Type of Building No. of Persons Type of Well pyc- Capacity t LAa, Purpose of Well 017, P 9166U I00 � s Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Certificate o lia .�"e hh been issued by the Board of Health. Signed __`�" 1 Date Application Approved ByZ�3� �/a Date Application Disapproved for the following reasons: Date Permit No. Issued Date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Compliance THIS IS TO CERTIFY,that the individual well Constructed( ), Altered( ), or Repaired by Installer at CIP n_4 , has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No.V-) '3 e )'-f —o a-(Dated � f L( THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector _ BOARD OF HEALTH _ TOWN OF BARNSTABLE VerY Cougtructiou PermitNo. tlj��o I I"/� G � \ Fee Permission is hereby granted to t����� k-),) \� �� \41.� Installer to Construct( ), Alter( ), or Repair ,annii'ndivi+dual well at: No. e v�Ccn. L A ) C_ �1V . Street as shown on the application for a Well Construction Permit No. ���z;✓� G �'` .Dated —2 / kj_ Date h Approved By �� � 7►b� i I T fr.rya r Apo Y ` � F 1 V o a `�- No. —yg 0 _ F — THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01pptication for ;moozaf bpaem Construction Permit Application for a Permit to Construct( )Repair(x3 Upgrade( )Abandon( ) ;E7 Complete System ❑Individual Components Location Address or Lot No. 44 Johnson Ln. Owner's Name,Address and Tel.No. Walter + Avis Ochs Assessor's Map/Parcel Centerville same -o Installer's e,A ss Tel.No. Designer's Name,Adores and Tel.No. n "m'. `: "odbinson Septic Servic David Mason P.O. Box 1089 East Sandwich, MA Centerville MA 02632 I)pe of Building: Dwelling No.of Bedrooms— Lot Size sq.ft. Garbage Grinder( ) Other Type of Building r e s i d ent i a 1 No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 930 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 11hoo :eXh Type of S.A.S. 3o aY I x,6 Description of Soil Nature of Repairs or Alterations(Answer when applicable) we will install a new Title-5 septic system to the plans of David Mason Dated 9/3/02 . Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b this B d Aealth. Signed ' Date ^ 7^Q Application Approved by Date ®— 0 Application Disapproved for the following reasons Permit No. .2 pre.L- 0 Date Issued d a U S Fe$e 5n 0 Y. THE COMMONWEALTH OF MASSACHUSETTS—- ., Entered in computer: ,"PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS ­4 2pprication for Migpoar &ps tem Conmructfon Permit Application for a Permit to Construct( )Repair(xX Upgrade( )Abandon( Complete System ❑Individual Components Location Address or Lot No. 44 Johnson In.. Owner's Name,Address and Tel.No. Centerville Walthe + Avis Ochs Assessor's Map/Parcel SSl®e /. -aa - Installer's - e,Address, d Tel.No. Designer's Name,Addre s' d Tel.No. v 'r`m. �. Robinson Septic Servic Davidf�Mason P.O. Box 1089 East Sandwich, MAS Centerville, MA 02632 Type of Building: ' Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building residentata1 No.of Persons Showers( ) Cafeteria( ) Other Fixtures \ Design Flow w gallons per day. Calculated daily flow S'30 gallons. Plan Date ~-1 Number of sheets Revision Date Title '°. Size of Septic Tank t10 h jl, e Type of S.A.S. Description of Soil N. x` Nature of Repairs orAltera ons(Answer when applicable) we will install a new Title-5 septic systeft to the plans of David Mason Dated 9/3[021 y \�13 Date last inspected: s ✓ya- 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 p de and not to place the system in operation until a Certifi- cate of Compliance has been issued b _oafd o. ealth. Signed Date Application Approved by � oat Date l U- �__U Application Disapproved for the following reasons r i Permit No. Ud a -yti 0 Date Issued /Gf,X�0 2 `-'lWhs THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,'MASSACHUSETTS Certificate of compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired.-x )Upgraded( ) Abandoned( )by Wm. E. Robineen Septic Ser$$ce at 44 Johnson Ln. , Centerville has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. Ord? Yh U dated /0-(r-U? Installer Wm. E. Robinson Sr. Designer David Mason The issuance of permit shall not be construed as a guarantee that the sysPwill function as d signed. Date 0 a Inspector ' ) No. ;? 0r)2-`/b0 14,50. 00 Ochs THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Oizpogaf *p.5tem Conotruction Permit Permission is hereby ranted to Construct( )Repair( x)Upgrade( )Abandon( ) System located at 44 Johnson Ln. , Centerville a< 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 t is ermitt. Date: ID r16 Approved by 4,j. TOWN OF BARNSTABLE �C- LOCA'eI `N yq SEWAGE # -20o9-q&(5 VILLAGE ASSESSOR'S.MAP & LOT INSTALLER'S NAME&PHONE NO. 806)50-) se ,ohc. SEPTIC TANK CAPACITY /000 7'Ao le 100a eutuQ .S b ba n LEACHING FACILITY: (type) La6u1, (size) NO. OF BEDROOMS BUILDER OR OWNER O di 5 PERMTTDATE: l D:g-©J1 COMPLIANCE DATE: 10-►S'0j 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 an f oca c 5 z A N IK \�k I r TOWN OF BARNSTABLE LOCATION qy -T&hntn,3 4..t,u SEWAGE # aoo -yob VILLAGE__ Q l -f e nv ll e ASSESSOR'S.MAP & LOT 2 LOi INSTALLER'S NAME&PHONE NO. se�obc, SEPTIC TANKrCAPACTTY 1oCX7 ►�;a„ k )oQc� Q�� 4� n„ LEACHING FACILITY: (type) emuk F- IJ (size) D b�; Sio j NO. OF BEDROOMS A BUILDER OR OWNER ®Ck S PERMITDATE: %Q=!Z-©X 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 1 Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furhished by i f o� A i A7 Le i Commonwealth of Massachusetts �,i Tifile 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 Johnson.Lane Property Address Lynne Ann Gerlach Turner Owner Owner's Name information is required for every Centerville MA 02632 Noyerber 17, 2011 page. City/rown 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 filling out forms A. General Information on the computer, use only the tab 1 Inspector: key to move your cursor-do not David D. Coughanowr, R.S. use the return Name of Inspector key. Eco=Tech Environmental r�s Company Name 43 Triangle Circle Company Address, Sandwich MA 02563 City/Town State Zip Code 508 364-0894 1328 Telephone Number License Number B. Certification -- I.certify that have personally inspected the s1.ewage disposal system at this address and that-the q. information reported below:is true, accurate and complete as of the time of the inspection. Thb 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 I;5.340 of Title-5(310 CMR 15.000).The system: i" Passes i ❑ Conditionally Passes ❑ Fails. ❑ Needs Further Evaluation by the:Local Approving Authority �Ccl (;;4— November 17, 2011 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. IQins,11110 TiUe 5 Official Inspection Form.Subsurfa Sewage-Dispo§al.System r Page of 17 i - Commonwealth of Massachusetts Y Title 5 official Inspection Form Subsurface Sewage Disposal System Form =Not for Voluntary Assessments 44 Johnson Lane Property Address Lynne Ann Gerlach Turner Owner owners Name information is required for every Centerville MA 02632 November 17, 2011 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C;D or E`7,always comolete.all of Section D A) System Passes: 0 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: Inspector's.Note==> The septic system described herein is deemed to pass this Real Estate Transfer Inspection if it does not meet any of the failure criteria enumerated.in Section D on pages 4-5. The scope of this inspection is limited to health and environmental compliance and the septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. 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 tankwill pass inspection if it isstructurally 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): 15ins•11/10 Title 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 44 Johnson Lane Property Address Lynne Ann Gerlach Turner Owner Owner's Name information i e required for every Centerville MA 02632 November 1,7,2011 page. Citylrown state. Zip Code Date of Inspection B. Certification (cost:) B) System Conditionally Passes (coot:): ❑ Observation of sewage backup or break outor 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 pipes) 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?11/10 Title 5 Official.Inspection form:Subsurface Sewage Disposal System-Page.3 of 17' 'Commonwealth of Massachusetts. — : Tit'(e 5 official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary.Assessments 44Johnson Lane Property Address Lynne Ann Gerlach Turner Owner Owner's Name information is requited for every Centerville MA 02632 November 17, 2011 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 aseptic 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:AllSystems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ z Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ N 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 '/2.day flow 15ins-11/10 Title Official Inspection form:.Subsurface Sewage Disposal System•Page 4 of 17 I . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 Johnson Lane Property Address Lynne Ann Gerlach Turner Owner Owner's Name information is required for every Centerville MA 02632 November 17,2011 page. citylrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less 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 16,000 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 ❑ Cl 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 I I 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. t5ms-11110 Tile 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts , Title 5 Official Inspection Form Subsurface SewageDisposal System.Form -Not for Voluntary.Assessments 44 Johnson Lane Property Address Lynne Ann Gerlach Turner Owner Owner's Name information is Centerville MA 02632 November 17, 2011 required for every page. Cityrrown State Zip;Gode 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 ❑ 0 Pumping information was provided by the owner, occupant, or Board of Health ❑ E were any of the system components pumped`out in the previous two weeks? ❑ 0 Has the system received normal flows.n 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) Q ❑ Was the facility or,dwelling inspected for signs of sewage back up? 1 ❑ Was the site inspected for signs of break out? © ❑ Were all system components, excluding the SAS, located on site? E ❑ 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: Z ❑ Existing information. For example, a plan at the Board of Health. 0 ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CM 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual); 3 DESIGN flow based on 310 CMR 15.203(for example: 11'0 gpd x#of bedrooms): 330 p t5ins•111110 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 44 Johnson Lane Property Address Lynne Ann Gerlach Turner Owner Owner's Name information is required for every Centerville MA 02632 November 17, 2011 page. Cityrrown 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?[if yes separate inspection required] ❑ Yes 0 No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? Yes ❑ No Water meter readings, if available(last2 years usage(gpd)): 192 gpd Detail: 2009, 2010 Sump pump? ❑ Yes 0 No Last date of occupancy: 1 year ago. 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/sgft:, 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: CSm4,!`:117tQ- Titte 5 Olficial Inspection Form:Subsutface Sewage Disposal System a Page 7'of.17 Commonwealth.of Massachusetts b, , Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 Johnson Lane Property Address Lynne Ann Gerlach Turner Owner Owner's Name information is required for every Centerville MA 02632 November 17, 2011 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/Use: Date Other(describe below); General Information. Pumping Records: Source of information: Was system pumped as part of the inspection?, ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping:` Type of System: 0 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(ta 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. 0 Other(describe). pump chamber 15ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Johnson Lane Property Address Lynne Ann Gerlach Turner Owner Owner's Name information is required for every Centerville MA 02632 November 17,2011 - page. CityrFown State Zip Code Date,of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Age: 9+years. Certificate of Compliance issued 10-18-02. (permit#2002-460). Were sewage odors:detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site.-plan): Depth below grade: 1.5feet Material of construction: cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Sewer line appears structurally sound with no evidence of leakage or backup. Septic Tank (locate on site plan): Depth below grader 1 feet Material of construction: M 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: 8 5 x 5 x 6- 1000 gallon tank Sludge depth: 4 in t5ins•11110 Title 5 Official Inspection Form: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 44 Johnson Lane Property Address Lynne Ann Gerlach Turner Owner Owner's Name information is required for every Centerville MA 02632 November 17, 2011 page. Cityfrown 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 30 in Scum thickness none Distance from top of scum to top of outlet tee or baffle 10 in Distance from bottom of scum to bottom of outlet tee or baffle 14 in How were dimensions determined? Design plan Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Liquid level at outlet inlet. Pumping not required at this time, but maintenance pumping is recommended within and every 2 years.Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. 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•11110 Title 6 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 44.Johnson Lane Property Address Lynne Ann Gerlach Turner Owner Owner's Name information is required for every Centerville MA 02632 November 17, 2011 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-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of17 Commonwealth of'Mas-sachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 Johnson Lane Property Address Lynne Ann Gerlach Turner Owner Owner's Name infgrmation is Centerville MA 02632 November 17, 2011 required for every page. City/Town State Zip:Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened)(Iocateon site plan): Depth of liquid level above outlet invert at outlet inverts. 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 appears structurally sound and functioning as intended. No evidence of leakage in or out was observed. Few solids in sump. Distribution is balanced using,flow equalizers. Pump Chamber(locate on site plan): Pumps in working order: Z Yes ❑ No Alarms in working order: Z Yes ❑ No Comments,(note condition of pump chamber, condition of pumps and appurtenances,etc.): Pump chamber appears structurally sound and functioning as intended. Float switch was activated and pump cycle was observed. Soil Absorption System (SAS) (locate,on site plan, excavation not required): If SAS not located,,explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 f Commonwealth of Massachusetts _ - - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 Johnson Lane Property Address Lynne Ann Gerlach Turner Owner Owner's.Name information is Centerville MA 02632 November 17, required for every 2011 page. City/Town State Zip Code Date of inspection D. System Information (cont.) Type: ❑ leaching pits nurnber: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: leaching fields number, dimensions: 1, 30 ft x 15;ft ❑ 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.); Soils above leaching field appear unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. An observation hole was dug into leaching field stone and no effluent contact staining was observed in the stone or overlying soils. No standing effluent was observed in field. Gesspools (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 ofgroundwater inflow ❑ Yes ❑ No 15ins a 11/10 Title 5 Official Inspection Form:Subsurface sewage Dispasal System•Page 0 of 17 Commonwealth of,Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Johnson Lane Property Address Lynne.Ann Gerlach Turner Owner Owner's Name information is required for every Centerville MA 02632 November 17, 2011 page. City/Town State Zip Code Date of inspection D. System, Information (cont.) Comments(note condition of soil, signs of hydrauiicfailure, 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.): 15ins•11110 title Official Inspection Form::Subsurface Sewage Disposal System-Page 14 of 17 "Commonwealth of'Mas�achusefts.- - I't"Ird 5 Offi lai Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 Johnson Lane Property Address Lynne-Ann Gerlach.Turner Owner Owner's Name information is e Centerville MA 02632' November 17, 2011 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cant:) Sketch Of Sewage Disposal.System: Provide a view of the sewage,di.sposal 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: OX hand sketch in the area below drawing attached Separately 5 l l I _2 s LEECH F1,551-D 2 t� W C x ..J t z6, t Z 2a%If 2? 3309 > tE ozo ��E 15ins 11110 Tale 5 Official Inspection Form:'Subsurfacb Sawago Disposbl;Sysfem.Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 Johnson Lane Property Address Lynne Ann Gerlach Turner Owner Owner's Name information is required for every Centerville MA 02632 November 17,2011 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ® Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 2.94 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: A survey instrument was used to determine the elevation of adjacent Lake Wequaquet and the outlet invert of distribution box piping. Design plan was then used to calculate elevation of bottom of leaching field, which is 2.94 feet above lake elevation. No Frimpter adjustment to existing water elevation is applicable in this case, because elevation of lake is controlled by means of a water level control wier at lake outlet. See diagram on page 15. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11110 Tdle 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 Johnson Lane Property Address Lynne Ann Gerlach Turner Owner Owner's Name information is Centerville MA 02632 November 17, required for every 2011 page. Citylrown 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-1 Ill 0 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 Johnson Lane Property Addrm Lynne Ann Gerlach Turner Owner pynrs Name Int0"ra0n b Centr3rvple requbed for every MA 02632 November 17,2011 page. Cityfrown state Zip Cade Date of Wsp mft D. System Information (cons) Sketch Of Sewage Disposal System Provide a view of the sewage disposal system,Including des 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 INK UOU'l MILD tu � y I 0-t3oX I' O 2 x !v� IA -X I tU;VhT(&W OF LAKE t i$• IS 34.160, RbTT o t1 OF: 'FIELD 15 3L .�), MINtMvM 5EtpgRPrTiotJ Z 24�z Z?" �S 1•q7 ;t Z,.q4 f't~ 1�Q•l7F i�E ow 111M TacosonwmwaWanFm=aftwf=swiwotw wtsymn,papisofp Commonwealth of Massachusetts . Title 5 Official Inspection Form , s � - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 't o 44 Johnson Lane, Centerville, MA 5O U SAC.f Property Address �1 , _ �^" Lynne G. Turner, 75 Boulder Road, Barnstable, MA `CSC J Owner Owner's Name information is Centerville MA /_ 02632-, 10/24/2011 required for ////// every page. City/Town State , Zip Cody' Date of Inspection � _ � ;� , , Inspection results must'be submitted on this form. Inspection forms may not be altered in any way. Please see completeness-Fi'ecklist`at the end'of,.the form. i 7 Important:When filling out A. General Information r forms on the I computer,use 1. Inspector. lS only the tab key I 1 to move your Reid C. Ellis cursor-do not Name of Inspector use the return a, key. Ellis Brothers Const. ' Company Name 24 Enterprise Road,, Company Address �D Yarmouth Port �� 1,.!! �f� MA 02675`. Cityrrown ` ' State Zip Code 508-362-6237 i S121891 Telephone Number I± ;f! I License Number r B. Certification` ,r I certify that I have personally i9spected.the sewage disposal system at tf is address and that e R information reported below is true, accuratif, e and complete as of the time of the inspection. The inspectionIL v was performed based on my training apd expeni nce in the-proper function and maintenance of on site sewage disposal systems..)am a DEPjapproved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15 000)�Tl e•system-`L� _,.'' ❑ Passes ElConditionally Passes Fatty r� C ❑ Needs Further Evaluation by the Local Approving Authority ' Ve e inspecto s gnature ` Date r aµra 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. L4 t5ins•11/10 Title 5 official Inspection Form:Subsurface Sewa 1 Disposal System•Page 1 of 17 ,1 � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 Johnson Lane, Centerville, MA Property Address Lynne G.Turner, 75 Boulder Road Barnstable, MA Owner Owners Name information is Centerville MA 02632 10/24/2011 required for every page. CityfTown State Zip Code Date of Inspection B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: have ast found.any information which indicates that any of the failure criteria described m 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: / J B) System Conditionally Passes: X1A ❑ One or more system components as des ribed in the"Conditional Pass"section need to be replaced or repaired. The system, upon mpietion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determin d"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years of *or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infill ration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is repl ced with a complying septic tank as i approved by the Board of Health. "A metal septic tank will pass inspection if it s structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less thi in 20 years old is available. ❑ Y ❑ N ❑ ND(Explain elow): t5ins-11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System'Page 2 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 Johnson Lane, Centerville, MA Property Address Lynne G.Turner,75 Boulder Road, Barnstable, MA Owner Owner's Name information is Centerville MA 02632 10/24/2011 required for every page. cdyfrown state Zip Code Date of Inspection B. Certification (cono B) System Conditionally Passes(cunt_): /V 4 ❑ Observation of sewage backup or break out r high static water level in the distribution box due to broken or obstructed pipe(s)or due to a b oken, settled or uneven distribution box. System will pass inspection if(with approval of Board of ealth): Elbroken pipe(s)are replaced ElY ElN ❑ ND(Explain below): Elobstruction is removed ElY ElN ❑ ND(Explain below): ❑ distribution box is leveled or replace J ElY ElN ElND(Explain below): ❑ The system required pumping more than 4 t mes a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval Df the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): t ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the BB�rdofealth: ❑ Conditions exist which require further evalu ition 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 Hea Ith determines in accordance with 310 CMR 15.303(1)(b)that the system is not functi ping in a manner which will pr ect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet a surface water ❑ Cesspool or privy is within 50 feet o a bordering vegetated wetland oria salt marsh k 15ins•11110 Title 5 Official Inspection Form:subsurface sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 Johnson Lane, Centerville, MA Property Address Lynne G. Turner, 75 Boulder Road, Barnstable, MA Owner Owner's Name information is required for Centerville MA 02632 10/24/2011 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) _ /� 2. System will fail unless the Board o Health(and Public Water Supplier, if any) determines that the system is functio ing in a manner that protects the public health, safety and environment: ❑ The system has a septic tank ani I soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tribi itary to a surface water supply. ❑ The system has a septic tank ano I SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank an SAS and the SAS is within 50 feet of a private water supply well ❑ The system has a septic tank and SAS ai id 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 analy is, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the prE sence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other bilure 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 El clogged of sewage into facility or system component due to overloaded or clogged SAS or cesspool ElDischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ElStatic 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 Y2 day flow t5ins-11110 Tifle 5 Of6aai trispection Form Subsurface Sewage Mi Wsal System-Page 4 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M s 44 Johnson Lane, Centerville, MA Property Address Lynne G.Turner, 75 Boulder Road, Barnstable, MA Owner Owner's Name information is Centerville MA 02632 10/24/2011 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cons) 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. . ElV 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 contac the Board of Health to determine what will be necessary to correct the V7 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"ye "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 f t of a tributary to a surface drinking water supply ❑ ❑ the system is located in a itrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mappe J Zone 11 of a public water supply well If you have answered"yes"to any question in ction 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 S tion E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.T e system owner should contact the appropriate regional office of the Department. t5ins•11/10 Tide 5 Official Inspection Form:Subsluface Sewage Disposal System•Page 5 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 Johnson Lane, Centerville, MA Property Address Winne G. Turner, 75 Boulder Road, Barnstable, MA Owner Owner's Name information is required for Centerville MA 02632 10/24/2011 every 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) z/ ❑ 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, occluding 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 sewagedisposal 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)1 D. System Information i Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual). ' D DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):' 15ins•11f 10 Title 5 Official Mnspection 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 44 Johnson Lane, Centerville, MA Property Address Lynne G. Turner, 75 Boulder Road Barnstable, MA Owner Owner's Name information is required for Centerville MA 02632 10/24/2011 every page. Cityfrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes M'*'No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes VNo Laundry system inspected? ❑ Yes [Pr__-No Seasonal use? ❑ Yes [ErNo I Water meter readings, if available(last 2 years usage(gpd)): Detail: _ --�� �� &,5-k-, Sump pump? ❑ Yes M4No Last date of occupancy: c;,zr�!_) > c> Date CommerciaUindustrial Flow Conditions: /0/11 Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/personsisq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 sys m? ❑ Yes ❑ No Water meter readings, if available: t5ins-11/10 Title 5 Official trupection 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 44 Johnson Lane, Centerville MA M Property Address Lynne G. Turner, 75 Boulder Road Barnstable, MA Owner Owner's Name information is required for Centerville MA 02632 10/24/2011 every 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: Wass stem pumped as part of the inspection? ❑ Yes M/No If yes, volume pumped: gallons How was quantity pumped determined? - lt Reason for pumping: Type of System: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins.11110 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 Johnson Lane, Centerville, MA Property Address Lynne G. Turner, 75 Boulder Road, Barnstable, MA Owner Owner's Name information is Centerville MA 02632 10/24/2011 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes M/N o Building Sewer(locate on site plan): 6 Depth below grade: feet Material of construction: a4st iron ❑40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 1600 (T Depth below grade: feet Material of construction: [/concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) � -4 tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificatg) ❑ Yes ❑ No Dimensions: � ✓ Sludge depth: t5ins•11/10 Title 5 Ofiaal Inspection Form: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 44 Johnson Lane, Centerville, MA Property Address Lynne G Tuner, 75 Boulder Road Barnstable MA Owner owners Name information is Centerville MA 02632 10/24/2011 required for every 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 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 4— How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related too t in ert,evidence of kage, et .): -� i�✓s<� � )A.q�� WPM �.4SW'tW � jl;�� 1W 7%�4- hz-e- 144�— /(f A 9 0� e A s Grease Trap(locate on site plan): Depth below grade: < feet Material of construction: ❑ concrete ❑metal ❑i berglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee c r baffle Distance from bottom of scum to bottom of oull et tee or baffle — Date of last pumping: Date 15ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments h 44 Johnson Lane, Centerville, MA Property Address Lynne G. Turner, 75 Boulder Road Barnstable MA Owner Owner's Name information is Centerville MA 02632 10/24/2011 required for every page. CitylTown State Zip Code Date of Inspection D. System Information (cunt.) 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 pu a/ time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal F 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-11/10 Title 5 Official Inspection Forth: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 44 Johnson Lane, Centerville, MA Property Address Lynne G.Turner, 75 Boulder Road Barnstable MA Owner Owner's Name information is Centerville MA 02632 10/2412011 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Distribution Box(if present must be opened) (locate on site plan)- ' Depth of liquid level above outlet invert ®10 _ � ��s j4j .4kPAlt, &dl Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evide=of l9e age into ote out of ox, etc._ )� A/1 -A4&0 �- Pump Chamber(locate on site plan). Pumps in working order. ( Yes ❑ No Alarms in working order: O/Yes ElNo Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): 4�p Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 01 t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 Of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 Johnson Lane, Centerville, MA Property Address Lynne G. Turner, 75 Boulder Road Barnstable, MA Owner Owner's Name information is Centerville MA 02632 10/24/2011 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: r d leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovative/altemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, et a % •. _ CAA -Mo A,14&be-1 01 'Aft-, + - Cesspools(cesspool must be pumped s� p o 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-11110 Me 5 OffieW 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 44 Johnson Lane, Centerville, MA Property Address Lynne G.Tumer, 76 Boulder Road, Bamstable, MA Owner Owner's Name information is Centerville MA 02632 10/24/2011 required for every page. Citylrown state Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): /vf54 Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 Johnson Lane, Centerville, MA Property Address Lynne G. Turner, 75 Boulder Road Barnstable MA Owner Owner's Name information is required for Centerville MA 02632 10/24/2011 every page. Citylrown state Zip Code Date of Inspection D. System Information (cunt.) 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 7whey public water supply enters the building. Check one of the boxes below: hand-sketch in the area below 5 ❑ drawing attached separately yr !a' 'Al t w .i L �I �J 3 4 �pt 15irre•11l10 Tft 5 Offi 1 tnW=n FWM Su8SWIMM 8WXW U1Sp W SYMM•PW 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments s 44 Johnson Lane, Centerville, MA Property Address Lynne G. Turner, 75 Boulder Road Barnstable, MA Owner Owner's Name information is required for Centerville MA 02632 10/24/2011 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellaryr�.vdl ��1✓L- ��'° ❑ Shallow wells C9Q 1NG� Estimated depth to high ground water. feet Please indicate all methods used to determine the high ground water elevation: r ❑ Obtained from system design plans on record If checked, date of design plan reviewed. Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: i�� 4 cr-L ZA, YouW11 must scribe how yoestablished the high ground water elevation: s� — Before filing this Inspection Report,.please see Report Completeness Checklist on next page. t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 Johnson Lane, Centerville, MA Property Address Lynne G.Turner, 75 Boulder Road, Barnstable, MA Owner Owner's Name information is required for Centerville MA 02632 10/24/2011 every 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 stem Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE ASSESSOR'S MAP & LOT ^,J A, INSTALLER'S NAME & PHONE NO. �VTM tAWD 2 Ll SEPTIC TANK CAPACITY LEACHING FACILITY:(type) �c�� �� (sue) S�� NO. OF BEDROOMS _PRIVATE WELL O BLIC WW BUILDER OR OWNER DATE PERMIT ISSUED: DATE COZIPLIANCE ISSUED: VARIANCE GRANTED: Yes No •1 rofnn t,�,6-t'�, sE�`•� �w K K 4Q��Ov uo f o4_f9.-D csZ Lsec�,c '�' low ASSESSORS MAP : / TEST HOLE LOGS ' PARCEL : 101 • t�' FLOOD ZONE : ��'"�.���✓ SOIL EVALUATOR : WITNESS REFERENCE : Z '"Z:) Oc0 " DATE : � PERCOLATION RATE : � I1+�11 V ...__.�._._ ._� . .._._ _._. ..__..._-....__..._._..M._._ .. . _. ,.._.--- -4). - A1,0 PA t _ nbi _ w TH- 1 TH- 2 UI -net) 6 oeo o ---—------- ' C)M 1, �•� ,,[[S ' I f lI/� (L _•__ __.. _ ___w r.._... .. .__. 45 '17- A-7 -FE101 LOCATION MAR `7+ y 1 J Mry(,J ��//����///yj�/�/■,',`� ■`r��.//•/fir, A6F ""Pip _ Aml SEPT 1 ; , Y8TAM DES I GN 7,6 . rLOW ES11 "o""" t b i1 1 �/���//f/may/ /�/{`^_•J.�j({/ �{�/'r'..J�) �+�{{�'��(i/}/�JV/�1�_/� —.{t'!..J,J T BEDROOM o 350 CAL/DAY _ « =.��j REDRD►�MS A . � CAL.IDAY/ 1 `�, 1 ��� c�•�.,1� ` , Y �Y 'Mc•-,..:+i l�.•C';�a.Ny��-N �' =�1 , 1• w.�.dr. ......w........ .....M.rw�.r. Is 45 SEPTIC TANK _ �,t�'w'^"mil'+ ' "i� l '. ' ' I h �! •�,11 w (�� R - AY x 2 DAYS GAS /A+ f)/► J�►ai��+ ��l,y-.t;R�N •t• •,�' ' �j ,., , ... '`,� t�;'. � ' - "r—�`�`.ww � (/a��'M� �•�7 ✓r �r G ' , ��.; : . .1 's � USE R) C) ALLt�N SP ` I C TANK .. . ._._ .__ _ _ 1 wt ,� • 1 � • SOIL A )ORPTION SYSTEM'KI eG, ;17 �� � •t° <,: � $ ' ,�, =3_+ 1 � +b"'!FA 1�/y�i_.+ �tom/ r. ~ �]�'7 _ ._.._._.._.•_ ,.._.__ __ Q Sp DE ARt�A i ,,�„�► BOTTOM AREA : �'` /� �., C,� 1 - S E c SYSTEM S ECT I ON F.-. _ mp wkn s / , �, r'fir ?`„ • r _ - �'r ..wl�) •r� M. -..._../3� , ,t .'. 4• , ,f',(. u •f'�t �'.'1 S.'•.�. ,...'t�•;,�:�^,n. yl D BOX + v a ti 00 GAL . .�.. ._ 00 S�PT I C TANK t%14�lohm . �. S 1 TE AN SEWAGE PLAN E: F-- LOCAT 1 ON . � ,y/ g� P R E R AR E D FOR A)467Z� , .r.._..._.._ ter' 725 7:-ee O 04,)0&.1 e0 Zo SCALE DAV I D B . MA S O N DATE : 0 - - r DBC ENV I RONMENiAL DESIGN \Ilk b EAST SANDWICH . MA ATE HEALTH AGENT t 508 ) 833 - 2177`